Taylor Wolfram Nutrition Counseling Interest Form

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Thank you for your interest in nutrition counseling! Please be sure to read the FAQs.

Taylor sees clients from 12-5pm Central Time on Tuesdays, Wednesdays and Thursdays only.

Please complete this form and we will be in touch shortly. Thank you!

Name *

Email address *

Phone number *

City and State (please note that depending on where you live, we may or may not be able to work with you due to state licensure laws - this is explained in our FAQs at taylorwolfram.com/faqs). We do not work with folks who are currently outside of the US. *

How do you prefer to participate in session? *

Telehealth (video meeting)

In person (at the office in Hinsdale, IL)

Required

How did you hear about us? *

Google

Insurance

Referral from healthcare provider

Recommendation from friend, family, neighbor, etc.

Instagram

Facebook

Twitter

Other:

Required

If another provider referred you to our practice, please list their name here.

Please describe the issues and/or concerns you wish to address in our work together *

We are in-network with BCBS PPO and out-of-network with all other insurance providers. It is your responsibility to verify your insurance coverage for nutrition services. If you have another insurance provider, we can provide a superbill to you upon request for you to submit your own claim. Please check one: *

I have BCBS PPO as my primary insurance provider

I will pay the full session fees out-of-pocket

Are you currently struggling with an eating disorder? (anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID, OSFED or unspecified eating disorder) *

Yes

I'm not sure

If you're currently struggling with an eating disorder, are you currently working with an eating disorder therapist? *

Yes

I am not currently struggling with an eating disorder

If you're currently struggling with an eating disorder, are you regularly seeing your medical provider such as a physician? *

Yes

I am not currently struggling with an eating disorder

Briefly describe your goals for our work together *

Confirm that you've read the FAQs (https://www.taylorwolfram.com/faqs/) *

Yes, I've read the FAQs

No, I haven't read the FAQs

Confirm that you agree to a weight-neutral approach and that our work will not entail intentional weight loss. *

Yes, I understand you will not put me on a weight loss plan

No, I am looking for a dietitian who will put me on a weight loss plan

Thank you! We will be in touch soon.

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