Nutrition counseling interest form

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Hi everyone! Please fill out this form if you are interested in working with Amanda Wagner, M.Ed, RDN, LDN of Amanda Wagner Nutrition PLLC.

I am currently able to work with clients in the following states due to state licensure laws: Arizona, California, Colorado, Illinois, Massachusetts, Michigan, Missouri, South Carolina, Virginia, and Wisconsin. I can also work with clients in other countries. If you live in a state not on this list feel free to still fill out the form, as I may be able to work with you in the near future or give you a referral. If you have any questions or concerns feel free to email me at amanda@amandawagnernutrition.com. A free 20 minute Discovery Call to learn more about my services is also available upon request.

NOTE: You don't have to be vegan, vegetarian, plant-based, and/or an athlete to work with me! I am able to help with a variety of concerns, goals, and lifestyles. I also work with individuals struggling with ARFID and suspected ARFID. I'll never pressure you to go plant-based in session! I'm all about meeting clients where ever they are.

Email *

Phone number (optional)

Name *

Where do you currently reside (i.e. Chicago, IL)? *

What is your preferred contact method? *

E-mail

Text message

Other:

How did you hear about or find Amanda Wagner Nutrition PLLC? *

Social Media (Instagram, Tik Tok, Facebook, etc.)

Search Engine

Physicians Committee for Responsible Medicine (PCRM)

Health Profs

Word of Mouth

Other:

If you answered other on the previous question please fill out.

What service(s) are you interested in? *

Ongoing one-on-one nutrition counseling

Lab interpretation and improvement plan (diet, supplements, and lifestyle)

Meal plans

Race/competition fueling plan

Other (please share more below if you select this option)

Required

Optional: If you answered other on the previous question about services you're interested in, please share ideas.

Are you able to financially commit to working with a dietitian at this time? *

Yes.

Most likely, but I need more information.

Not yet.

Why do you want to work with me? Feel free to share some of your reasons and/or goals below. *

Send me a copy of my responses.

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