Nutrition Instincts Inquiry
Please note: If you are reaching out to us for care for an eating disorder, we will require that your physician (and prior treatment team when applicable) fax us your most recent lab work, growth charts (if applicable), and chart notes that verify you are safe to be seen outpatient and regularly monitored by a physician. Our fax number is 858-924-0506. If you're having trouble accessing insurance and as a result do not have a doctor, please call 211, a free service in San Diego, to receive assistance with finding insurance coverage that is accessible to you. 
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First Name *
Last Name *
Pronouns *
Gender Identity *
Email Address *
Phone *
Birthday *
of client
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/
DD
/
YYYY
Who is making this inquiry? *
Parent/Legal Guardian/Caregiver First & Last Name
Required if potential client is a minor/you're inquiring for another
Parent/Legal Guardian/Caregiver Phone Number
Required if potential client is a minor/you're inquiring for another
Parent/Legal Guardian/Caregiver Email
Required if potential client is a minor/you're inquiring for another
What services are you interested in receiving? *
Required
Which of our specialties are you interested in? *
Required
Please select your preferred location *
Required
Are you familiar with the HAES/weight inclusive approach? *
Were you referred to us? If so, by whom? *
If not, how did you find us? Google? If so, what terms did you search? This helps us reach more people who need our services!
What is your availability for appointments? (days, times) *
Any additional information you'd like to provide or questions you'd like to ask? *
Are you ready to schedule your initial assessment? *
Please add me to your newsletter for free resources, supportive content and practice updates. *
Please note that regardless of whether you opt in here, if you become a client you will be included on practice-only emails that are sent out 2-3 times a year (i.e. notifications of policy changes, fee changes, new insurance we're accepting, etc...)
Required
What is your primary insurance? *
Check your insurance card to be sure your reply is accurate.
If you're out of network, do you plan on pursuing a single case agreement? *
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