1:1 Client Application

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1:1 Client Application

Hi there!

Please fill out this application and I will reach out if we are a good fit and your goals are within our area of expertise. Applications are read as they come in, and it may take up to a week for us to review yours and reach out to you.

Make sure to check your spam folder and make sure emails from emmy@therealgoodnutrition.com and jackie@therealgoodnutrition.com are set to go to your inbox.

Looking forward to chatting with you soon!

Emmy & Jackie

Some fine print:

- Please be ready to work together when you are contacted. If you are not sure that you will want to work together, reach out to Emmy to chat before applying.

- Only available to adults ages 18+

- Only available to those who are residents of AZ, CA, CO, IL, MI, MN, OR, VA, WA, and WI. If we are not a good fit, you may or may not receive an email from us to follow up.

I read the fine print.

Required

First & Last Name *

Email Address *

Birthdate *

By submitting this form, you are agreeing that you understand our eligibility requirements for age.

YYYY

Phone Number *

What state do you live in?
*

By submitting this form, you are agreeing that you understand our eligibility requirements for location.

Which dietitian would you prefer to work with?
*

Note that we may or may not be able to match you with your preferred dietitian depending on availability and your needs as a client, but we will always do our best!

Not sure? Get to know us first! :)

For Emmy's bio and specialties, click here.

For Jackie's bio and specialties, click here.

Emmy Bright

Jackie Jozefiak

Either!

Where did you hear about Real Good Nutrition? *

Instagram (thanks for following! 😊)

Internet search

Friend or family referral (if so, please choose "Other" and write their name)

Doctor/provider referral (if so, please choose "Other" and write their name)

Therapist referral (if so, please choose "Other" and write their name)

HealthProfs

Google

Yelp

Other:

If you plan to use insurance:

We only accept BCBS Anthem and FSA/HSAs for appropriate diagnoses.

Please note that BCBS Anthem is not the same as other BCBS plans.

Are you planning on using BCBS Anthem or FSA/HSA for your sessions?

Clients will not be chosen on the basis of whether they are using insurance or not.

Yes, I am planning on using BCBS Anthem

Yes, I am planning on using my FSA or HSA

I do not have BCBS Anthem or an FSA/HSA and I understand all costs will be out of pcoket

FYI: If you are planning on using BCBS Anthem, you will be asked to fill out two forms to verify your insurance eligibility and obtain the necessary documentation of your diagnosis from your doctor or other provider.

Please select the health condition(s) that you are hoping to work on: *

GI diseases (i.e. Celiac, IBS, IBD, GERD, gastroparesis, diverticulosis, fatty liver, etc.)

Digestive health issues (i.e. chronic bloating, constipation, diarrhea, reflux, etc.)

Eating disorder(s), disordered eating, chronic dieting

Polycystic ovarian syndrome (PCOS)

Thyroid issues (hyppothyroidism, hyperthyroidism, Hashimoto's, etc.)

Autoimmune diseases (RA, Lupus, etc.)

Pre- or post-natal

Cardiovascular health (heart disease, hypertension, high cholesterol, etc.)

Diabetes

Unintentional weight loss / help to regain weight

Hypothalamic amenorrhea

Skin and/or hair concerns (chronic acne, hair loss/thinning, etc.)

I don't have any health conditions.

I have health conditions, but I don't need to work on them with my dietitian.

Other:

Required

Which of the following sounds the most like you? *

My main goal is for my dietitian to help me lose weight.

My main goal is to improve my overall health/manage my condition, and while I wouldn't mind if I lost weight, I'm ok if that doesn't happen.

I have no weight loss-related goals.

Do you want help improving your relationship with food? *

(i.e. quit the diet cycle, stop feeling guilty/shameful for food choices, get rid of food rules, learn to eat without a diet, improve body image, find weight neutrality, etc.)

Yes!

Nope, I'm good.

What is your reason for wanting to work with us, and what do you hope the outcome of working together will be?

If you'd like help with a specific diagnosis, please add that below.

Just a few sentences please!

Packages start at $470. Please click the box below to confirm that you have reviewed our pricing on the website. *

I've reviewed the pricing options and I'm ready to go!

I've reviewed the pricing options and I don't want to move forward right now. (Totally ok! Have you checked out Emmy's program called Real Good Intuitive Eating? It's a 12-week program that will give you all the same tools & resources that Emmy uses with her clients at a lower cost-per-session!)

Required

Which of the following sound the most like you?
*

I am ready and able to invest time and resources into improving my health and/or relationship with food for the long run.

I want to get started but I'm not sure if now is the right time and/or if it fits in my budget.

If we're a good fit, how soon can you get started?

Note: If you are not ready to get started right away or do not know when you would want to start, please do not apply quite yet.

If you are contacted by us and you do not wish to work together right away, please know that you will need to apply again when you are ready to do so - your spot will not be held. Thank you for understanding!

By submitting this form, you'll be added to the Real Good Nutrition newsletter, but you can unsubscribe anytime you want to (no spam, I promise!). *

Gotcha! I understand.

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