Name *

First Name

Last Name

Name of person filling out form (if different than client)

First Name

Last Name

Phone *

(###)

###

####

What kind of support are you seeking? *

Eating disorder/disordered eating recovery

Meal planning brainstorm session

Intuitive eating

General wellness

Meal support session

Management of a chronic condition (e.g. IBS, Diabetes, GI symptoms, etc.)

Family based therapy for eating disorder support

As dietitians, we need to get a referral from another health care provider for our services (regardless of whether your insurance says you need one). Are you able to work with your team to get a referral emailed to us? *

Yes!

I am not able to at this time, and I need some referrals.

Our Nourished Bodies is currently in-network with American Specialty Health, Anthem Blue Cross, Aetna Commercial Health and Aetna Medicare. Are you planning to utilize insurance to cover your sessions? *

Yes!

No, I will be utilizing cash pay and require monthly superbills.

Please confirm that you have reviewed the Insurance FAQs and understand that you will need to call your insurance company to verify your coverage. *

Yes

I am not planning to use my insurance benefits.

Our Nourished Bodies' approach is improving overall wellness, rather than focusing on weight *

i.e., a weight-inclusive, Health At Every Size aligned approach

I understand!

I have some questions on this approach!