Intake form Pediatric Child

New Client Intake Form - Client <18

* Indicates required field

Name *

First

Last

Preferred Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Mobile Phone Number *

Home Phone Number *

Parent #1 *

Parent #1 Phone *

Parent #2 *

Therapist *

Parent #2 Phone *

Therapist Phone *

1. What has brought you to see a dietitian? *

2. What concerns do you have about your relationship with food and what changes do you want to make? Today? Long Term? *

3. What problems do you see in your eating habits and what things would you like to change? *

4. Are you comfortable with your body or have you struggled with your weight? *

Cancellation Policy
Please contact me up to the day prior to your visit if you should need to change or cancel your appointment. All same day cancellations or no-shows will be charged the full session fee.

Cancellation Agreement *

I have read the cancellation policy, and agree that all same day cancellations will be charged in full

Submit