Taylor Wolfram LLC Nutrition Counseling Interest Form
Please note: While Taylor is not currently accepting new clients, Jessica is taking new clients on a case-by-case basis.
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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) *
Please describe the issues and/or concerns you wish to address in our work together *
If another provider referred you to our practice, please list their name here.
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: *
Are you currently struggling with an eating disorder? (anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID, OSFED or unspecified eating disorder) *
If you're currently struggling with an eating disorder, are you currently working with an eating disorder therapist? *
If you're currently struggling with an eating disorder, are you regularly seeing your medical provider such as a physician? *
Briefly describe your goals for our work together *
Confirm that you've read the FAQs (https://www.taylorwolfram.com/faqs/) *
Confirm that you agree to a weight-neutral approach and that our work will not entail intentional weight loss *
Thank you! We will be in touch soon.
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