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Pivot Nutrition Program Application
Please answer these questions to submit your application to get started working with me!
Learn more about me on my website
www.pivotnutritionri.com
or my Instagram page
@balanced.fueling
You can
book a free intro call by clicking here!
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Full Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
What are you looking for help with? Check all that apply.
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Sports/Performance Nutrition
Mindful Eating Skills
Sustainable Behavior Change/Healthy Habits
Meal Planning
Fat Loss (Body composition goals)
Building Muscle/Lean Mass (Body composition goals)
Heart Healthy Nutrition (improve cholesterol levels and/or glucose control)
Improve relationship with food
Learning what my body needs (macronutrients/micronutrients, etc.)
Binge Eating
Emotional Eating/Stress Eating
Body Image Work
General Nutrition & Wellness
Accountability & Emotional Support
Other:
Required
What are your biggest challenges with food/nutrition and eating habits?
Your answer
What are your biggest challenges with healthy lifestyle habits (fitness, sleep, stress management, etc.)?
Your answer
What payment method do you plan to use?
*
Blue Cross Blue Shield (Health Insurance)
United Healthcare (Health Insurance)
HSA/FSA account
Private Pay
Not Sure
What type of visit/appointment do you prefer?
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Virtual (zoom)
In-person (At my office located at 145 Elmgrove Avenue, Providence, RI 02906)
No preference/either one works.
What days of the week are you available for meeting? Check all that apply
Monday
Tuesday
Wednesday
Thursday
Friday
What times of day are you available to meet? Check all that apply.
Early Morning (7:30-9:30am)
Late Morning (9:30am-11:30am)
Mid-Day (11:30am-2pm)
Late Afternoon (2pm-4pm)
Early Evening (4pm-6pm)
Late Evening (6pm or later)
Please comment on any other schedule preferences related to your availability.
Your answer
What does your ideal coaching program look like, entail, include to set you up for the most success?
Your answer
If weight loss is your goal, rather than focusing on just the scale, are you willing to take an approach that focuses on sustainable, realistic behavior change and mindful eating?
Your answer
If we decide we're a good fit to work together, would you be ready to make a premium investment in your health?
Very Ready: I know that investing in my future health is what I need and I am ready to reach my goals!
Somewhat Ready: I'm figuring out if this is the right investment but I do want to make changes.
Not Ready: I'm not in a place where I feel like I can invest in my health goals right now.
Clear selection
If you plan to go through health insurance, please provide your mailing address, Insurance name, ID#, and group number (if applicable) and I will check to see if your appointments are covered!
Your answer
Please describe any additional helpful information you'd like me to know (including more info on your goals/history, and if anyone else is involved in the decision-making process).
Your answer
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