Embodied Nutrition: New Client Request

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Please fill out this form to request nutrition counseling services. Please note, I only see clients aged 16 and up. If I have an open spot within your availability I will reach out to schedule with you. If not, I will let you know that you have been added to the waitlist.

Email *

Name *

Date of Birth *

YYYY

What is your preferred phone number? *

What nutrition services are you interested in? *

Individual nutrition counseling for eating disorder recovery

Individual nutrition counseling for healing chronic dieting

Non-diet individual nutrition counseling for health concerns

Individual meal support sessions

Parent consult for teens (12-17)

Intuitive Eating Group Program (Sept 2023)

I'm not sure

Required

What prompted you to seek nutrition counseling? Include as many details as you feel comfortable sharing so that we can make sure working together is a good fit. *

What is your preferred form of payment? *

Private pay ($190 for initial assessment, $140-165 for follow ups)

Blue Cross Blue Shield

Mass General Brigham Health Plan (formerly Allways)

Harvard Pilgrim Health Care

You don't take my insurance and I am willing to pay out of pocket at this time (a monthly Superbill can be provided for OON benefits)

What is your availability for sessions? Please note that I do not see clients on Wednesdays at this time. We can meet virtually (if you reside in MA, IL, or FL) or in-person if you are local to the North Shore. My office is in the Cummings Center in Beverly, MA.
*

Would you like to be added to a waitlist if there are no immediate openings for your scheduling needs? *

Yes

Would you like to be added to the email list for newsletters and practice updates?

Yes

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