Prospective Client Info Form
This is an information form for prospective clients to share more about what your are looking for and your goals for nutrition services. Once you have submitted the form, you will be added to a waitlist, and contacted once a space has opened up.
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Email *
First Name *
Last Name *
City and State *
Age *
Please acknowledge that you have reviewed our rates. We can offer a "Out of Network Benefits Script" for you to determine what reimbursement you may receive from insurance. We also reserve a small number of sliding scale spots. Please indicate if you need either of these resources. *
Required
How did you find out about Wise Heart Nutrition? *
If referred, by who?
What health conditions do you currently have or have had in the last 2 years? *
Required
Please select any health care providers you are currently working with *
Required
What are your goals for working with a provider at Wise Heart Nutrition? *
What are your biggest challenges right now in your relationship with food? *
What would you like your relationship with food to look like 6 months from now? *
How do you feel about taking an anti-diet and weight-neutral approach to your health and wellbeing? *
What else would be helpful for Wise Heart Nutrition providers to know about you? *
Are you willing to commit time and energy each week between sessions to explore and work on your relationship with food? *
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