Danielle Hooker, MS, RDN, LDN - Appointment Request

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Due to upcoming maternity leave, I am not accepting new clients at this time. However, please complete this form if you would like to be added to my waitlist for when I return.

Please note that requests submitted after June 25th will not be reviewed until I return. If you are looking to begin services sooner, please reach out to Jocelyn Dixon, MS, MPH, RDN, LDN.

Thank you so much for your understanding!

Email *

First and last name: *

Phone number: *

Preferred method of contact: *

Phone

Required

Date of birth: *

YYYY

Address (street address, city, state, zip): *

Please provide a brief description of your nutrition counseling needs: *

Do you prefer in person appointments or virtual? *

In person at 6604 Six Forks Rd, Suite 101, Raleigh, NC 27615

Virtual

Either is fine with me

How did you hear about our practice? *

Are you currently seeing a mental health counselor/therapist at Cornerstone Counseling and Wellness, PLLC?
*

Yes

If yes, please list name of Cornerstone staff member you are currently working with:
*

Please list name, address, and phone number for Client's Primary Care Physician?
*

Emergency contact name (First and Last): *

Emergency contact phone number: *

Emergency contact relationship to client: *

The insurance companies below are the ones with which Danielle Hooker, RDN, LDN is IN-NETWORK. Please specify which insurance company below covers your mental health benefits. If you have a different insurance provider other than these or are uninsured, please choose "None of the above/Self-Pay." PLEASE REFERENCE THE BACK OF YOUR INSURANCE CARD WHEN ANSWERING THIS QUESTION, as your mental/behavioral health benefits may be outsourced to an insurance company that differs from the one that manages your health benefits.
*

Aetna

Aetna State Health Plan

Blue Cross Blue Shield: CHOOSE THIS OPTION ONLY IF YOU HAVE ONE OF THE FOLLOWING PLANS: PPO, Blue Value POS, Indemnity, Blue Care HMO, Blue Home with Novant Health (Not UNC Health Systems), Blue High Performance Network (HPN) Duke, BCBS Federal, BCBS Student Blue

None of the above/Self-Pay: If you choose this option, please skip the remaining questions and submit the form.

An additional questionnaire may be sent to you from the Registered Dietitian prior to your first appointment.

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