WORK WITH ME NAME * First Name Last Name PRONOUNS (OPTIONAL) BIRTHDATE MM DD YYYY PHONE * (###) ### #### EMAIL * PREFERRED CONTACT METHOD * Call Text Email HOW DID YOU HEAR ABOUT ME? * WHAT KIND OF SUPPORT ARE YOU SEEKING? * Eating disorder/disordered eating recovery Intuitive Eating Nutrition support for fertility Breastfeeding education and location support Meal Planning DO YOU HAVE A MEDICAL DIAGNOSIS FROM YOUR DOCTOR OR THERAPIST FOR WHICH YOU ARE SEEKING SERVICES FOR? IF SO, WHAT IS THE DIAGNOSIS? Example answers: "I have a diagnosis of F 50.0 Anorexia Nervosa." "I do not have a diagnosis but I suspect I am struggling with Bulimia." DO YOU HAVE ANY OTHER MEDICAL OR MENTAL HEALTH DIAGNOSES THAT YOU WOULD LIKE TO SHARE? AVAILABILITY * Please list the best days and times of the week that you are available for sessions. IS THERE ANYTHING ELSE YOU WOULD LIKE TO SHARE WITH ME? Thank you!
