Nutrition Elevated Prospective New Client Form

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Hello! Thank you so much for your interest in working together. As of January 2024, I have limited availability in my schedule to see new clients. If you are interested in working together, please complete the form below.

Once I receive your submission, I will get back to you within 72-business hours with either:

An email update with an estimated wait time, OR
The link to schedule a complimentary 10-minute Meet & Greet video call.

Thank you!

Are you reaching out on behalf of yourself or a child?

**To ensure the protection of client privacy, Nutrition Elevated will not accept visit requests from parents or caregivers on behalf of their dependents (18 years and older). If your child is 18 years and older, they will need to contact Nutrition Elevated directly to establish care. At their first visit, we will discuss if they feel comfortable signing a HIPPA Release Form for parents/caregivers.

Myself

Adolescent/child (13-17yo)

Young adult dependent (>18yo)**

How did you hear about my services? *

Referral from provider

Referral from a friend

Google Search

Health Profs

Instagram

Facebook

Other:

Required

If another provider referred you to my services, please share their name below: *

What is YOUR first & last name? *

Your Phone number *

Your Email Address *

What is your child's name? *

How old are you? (or your child) *

Please confirm that you agree to the following: for legal reasons, all clients must be physically located in Washington State for every nutrition visits, even virtual visits. *

Yes, I understand that I must be physically located in Washington State during ALL nutrition visits (virtual and in-person).

Have you (or your child) been diagnosed with an eating disorder? *

Yes

Other:

Have you or your child ever been hospitalized for an eating disorder? *

Yes

N/A

What are you (or your child) seeking support with? (Select all that apply) *

I'm not sure yet!

ADHD and nutrition challenges

Anorexia nervosa

ARFID

Bulimia nervosa

Binge eating disorder

Disordered eating counseling

Fueling for the outdoors

OSFED

Intuitive eating

I want to become a diet culture drop out!

Sport and performance nutrition

Other:

Required

Please include any additional details about why you are interested in nutrition counseling: *

Please check all that apply:
*

I am concerned that I have an undiagnosed eating disorder

I’m worried about my relationship with food

I want to stop dieting

I have thoughts of dissatisfaction about my body

I worry that I exercise too much and/or for the wrong reasons

I want to stop overeating and/or bingeing

This is my first time seeking care for my relationship with food and/or body image

My concerns with food and body image are relatively new

I’ve had issues with food and body image my whole life

None of the above apply

Required

How motivated are you (or your child) to engage in treatment? *

Strongly motivated - I'd like to start ASAP

Motivated

Somewhat motivated

Not personally motivated, but want to appease a family member, partner, or friend.

I am (they are) only here because my (their) treatment team (or another health provider) recommended that I (they) see a dietitian.

Nervous/anxious more than anything

I don't know

Other:

Are you (or your child) currently seeing a therapist? *

Yes, a general therapist

Yes, an eating disorder therapist

No, but I am interested in establishing care with a therapist

Other:

Are you interested in virtual or in-person visits? *

I prefer all virtual visits

I prefer all in-person visits

I prefer a mix of in-person and virtual visits

Other:

Required

When would you (and/or your child) be available for regular visits? *

Tuesday mornings

Thursday mornings

Thursday afternoons

Friday mornings

Friday afternoons

Required

Who is your insurance provider? *

Please confirm that you understand the following regarding insurance: *

Nutrition Elevated is an in-network provider with Regence, UnitedHealth, and First Choice Health.

Nutrition Elevated in currently an in-network provider with Premera, but will be an out-of-network provider after May 16, 2024.

Nutrition Elevated is an out-of-network provider will all other insurance companies, but will provide clients with a SuperBill that can be used to request reimbursement from their individual insurance company.

Upon request, Nutrition Elevated can submit a Superbill to your insurance provider on your behalf.

Required

Confirm that you have read the Financial FAQ's and understand the following: *

Yes, I have read the Financial FAQ's

Yes, I understand that 10-15 minutes of care coordination/treatment updates (via email or phone) are "included" in the cost of each visit.

Yes, I agree that if I request any services outside of direct client care (such as meal plans, support letters for school or coaches, parent/client/provider care conferences, etc.) that these cannot be billed to insurance. Therefore, I will need to pay for these services out-of-pocket.

Yes, I understand that parent or caregiver-only nutrition visits (when the minor client is not present) cannot be billed to insurance and parents/caregivers will be responsible for paying out-of-pocket for the visit.

Required

Thank you so much for taking the time to fill out this form!

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