Name

Email Address

Date of Birth

What state do you live in?

Phone Number

I'm looking for support around I'm looking for support around An Eating Disorder Disordered Eating Body Image Concerns Emotional/Binge Eating Intuitive Eating Medical Nutrition Concerns Healing My Relationship to Food Services/Support for my Teen (please select all that apply to them as well!) Other

We work with clients to heal their relationship to food, with an emphasis on wellness and health without the goal of weight loss. Are you ready to explore this relationship without weight loss as the focus? We work with clients to heal their relationship to food, with an emphasis on wellness and health without the goal of weight loss. Are you ready to explore this relationship without weight loss as the focus? Yes No, thank you! I'm not sure if I am, but I'd love to hear more about this! Other

Would you be interested in scheduling a call to learn more about our services? Would you be interested in scheduling a call to learn more about our services? Yes No Would prefer to communicate via email

What health insurance do you have? *Please note, we are currently only in network with IBX, BCBS and Aetna plans* What health insurance do you have? *Please note, we are currently only in network with IBX, BCBS and Aetna plans* Aetna Highmark Blue Cross Blue Shield Independence Blue Cross Cigna United Other

Our providers identify as male or female. Do you have a preference of provider? (required) Our providers identify as male or female. Do you have a preference of provider? (required) Female Male No preference

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