Name *

First Name

Last Name

Phone *

(###)

###

####

Gender *

Female

Male

Prefer not to say

Do you plan to use Insurance? *

YES

NO

Do you know if your health insurance covers nutrition counseling?

**If you’re not sure, call the customer service number on the back of your health insurance card and ask about coverage.

YES

NO

Have you worked with a Licensed Registered Dietitian before? *

YES

NO

What are your health concerns? *

select all that apply

Weight Management (Weight Gain/Obesity)

PCOS

Endometriosis

Acne

Irregular Periods

Fertility Struggles

High Cortisol

Insulin Resistance/Prediabetes

Eating Disorder

Binge Eating Disorder

Emotional/Overeating Eating

Disordered Eating

IBD/IBS

Autoimmune Disease

Corporate Wellness

Other