New Client Questionnaire

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Stanton Nutrition Counseling, LLC

Name of person completing this form: *

Name of prospective client (If different from the name above, please share your relationship with this person)

Client age *

Phone number (if filling out this form for a minor client, please list your number) *

Email address (if filling out this form for a minor client, please list your email address) *

How did you hear about us?

Which do you prefer? *

In person services only

In person, but I'm open to virtual / telehealth (note - this option can often reduce wait time for appointments)

Virtual only

Either is fine / No preference

Please select the area(s) in which you wish to receive support. *

Intuitive Eating

Eating disorder / Disordered eating behaviors

Chronic dieting / Weight "cycling"

Body image

General or preventative nutrition

Pre-diabetes / Diabetes management

Cardiovascular / Heart concerns

Other:

Required

Please provide additional information about the specific diagnosis, concern, or nature of the problem. *

Please read carefully: Stanton Nutrition Counseling, LLC is an insurance-based practice and can bill in-network insurance providers for services provided. Even if you do have insurance, according to your specific plan, you may have a cost share (i.e. deductible, co-pay, etc) that applies or services may not be covered. You are responsible for knowing your benefits, but we are happy to help you navigate finding out this information before scheduling an appointment. If you do not have insurance or have insurance that considers our providers "out of network," you are responsible for payment at time of service. You may use your HSA or FSA to pay for services. A superbill can also be provided upon request to submit to your insurance provider for reimbursement. *

I have read and acknowledge the above information

Required

If you plan on using insurance, please check your insurance provider(s). Note - we are only in network with those listed below.

Aetna

Anthem Blue Cross Blue Shield

Cigna

United Healthcare

UMR

Other:

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When is your availability for appointments? (check all that apply)

Weekday mornings

Weekday afternoons

Weekday evenings

Weekends

Other:

Are you in need of any accommodations for an appointment (i.e. wheel chair accessibility, interpretation services, need to bring a service animal, etc)?

Anything else you would like for us to know prior to contacting you to set up an appointment?

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