New Client Application

Thanks for your interest in working with me! Please fill out the application form below to see if I can help meet your needs. All information is kept secure and confidential in compliance with U.S. privacy laws (HIPAA). A member of my staff will get back to you as soon as possible to answer any questions and let you know if we're able to book an appointment.

Please note that I offer coaching via phone and video for clients who are pursuing intuitive eating, Health at Every Size, and recovery from dieting or subclinical disordered eating. Virtual coaching is not appropriate for people struggling with active eating disorders; please see the "Working With Me" section of the nutrition counseling & coaching page for details. At my office in Brooklyn, NY, I offer nutrition counseling for clients pursuing intuitive eating, eating disorder recovery, and Health at Every Size®. In-person sessions are eligible for insurance reimbursement. 

Name *
Name
Phone *
Phone
Please note that some states require in-state licensure for all nutrition therapists. If necessary, we will make an effort to obtain the required license for an additional fee.
Please select the option that best describes your main reason for seeking nutrition therapy:
Current health conditions *
Please check all health conditions you've had in the past year:
Please list any additional health conditions you've had within the past year.
Please note any health conditions you've had in your life prior to the past year.
Current treatment team *
Please select any healthcare providers you currently see:

 

NEW CLIENT FORMS

Once you've heard back from us to schedule an initial appointment, please download and complete our new client registration forms before your session. Thanks and we look forward to working with you!