Screening Tool Nutrition Services Clients
Nutrition Services Assessment
Sign in to Google to save your progress. Learn more
Email *
LifeBalance Screening Tool Nutrition Services
Alexis Spink, RDN LDN is a Registered and Licensed Dietitian Nutritionist who specializes in the treatment of Eating Disorders, disordered eating and chronic dieting. She has over 5 years of extensive training and work experience in the Boston area in all levels of care in the field of Eating Disorders and co-existing mental health conditions; including 3 years at the Cambridge Eating Disorders Center Residential and Partial-Hospitalization Program as a full-time RD.

Alexis offers evidence-based nutrition counseling for those with a history of chronic dieting, disordered eating behaviors, feeding concerns and eating disorders of all diagnoses. Her primary focus is on the treatment of the whole person with a non-diet approach. Her counseling strategies are shaped by Intuitive Eating principles to guide her clients in establishing a healthier relationship with food and body image. To see her clients experience healing in their relationship with food and body is her goal and passion.

Please complete this form to help us get a picture of your needs and identify if we can accommodate your needs.
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender Identity *
Address
City
State
Zip Code
Contact Phone Number
Is it okay to text you?
Clear selection
Contact Email Address
Name of Insurance Company
Insurance ID #
Please let us know days of the week and times of the day you will be available for regular Nutrition appointments?
Please check all that apply:
Have you seen a dietician or nutritionist before:
Clear selection
Was it in the past 12 months/ when? (please describe those services) *** skip if you have not seen a nutritionist before
Have you ever been told by a doctor that you have diabetes? (please describe if yes, certain conditions related to diabetes must be managed by a specialized nutritionist, Alexis is able to help with many clients but not all)
What are your primary reasons/ complaints for meeting with the dietician?
Have you checked with your insurance to see if they cover nutrition services (some insurances do not, and all will require a referral from your primary care doctor) please have them fax benefits for you to 603-601-4476 after completing this form.
Clear selection
Do You Have a Referral From Your Primary Care Doctor (please have one faxed to 603-332-8000 Attn: Alexis Spink RDN LDN
Clear selection
Do You Have Any Medical Labs to Share With the Nutritionist From the Past Six Months (please have labs faxed to 603-601-4476)
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of LifeBalance Administrative Services. Report Abuse
Google Forms