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New Client Intake Form
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Name
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Address
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Mobile Phone Number
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Home Phone Number
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Primary Care Provider
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Primary Care Phone
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Therapist
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Where did you hear about my practice? Please list provider or website
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Preferred Payment
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1. What has brought you to see a dietitian?
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2. What concerns do you have about your relationship with food and what changes do you want to make? Today? Long Term?
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3. What problems do you see in your eating habits and what things would you like to change?
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4. Are you comfortable with your body or have you struggled with your weight?
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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
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I have read the cancellation policy, and agree that all same day cancellations will be charged in full
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Home
About Julie
Location
Fees
Blog
Schedule an Appointment
In The News
Forms