Let’s work together

Ready to book your first appointment? Fill out some info and I will be in touch shortly! I can't wait to hear from you!

Name

First Name

Last Name

Pronouns

Phone

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What state do you reside in?

Are you planning on using insurance benefits?

If yes, please list the company that holds your insurance policy.

How did you hear about me?

If a provider referred you, please list them here.

What prompted you to reach out?

Are you filling out this form for yourself or for a child in your care?

If you are filling out this form for yourself, are you over the age of 18? If you are not over the age of 18, will a parent, guardian, or caregiver be a part of your care?

Is there any additional information you would like me to know?

I understand that it can feel vulnerable sharing your history with someone you have not met yet. Use this space to share what you feel comfortable sharing. This could include the following: Are you reaching out for you or a loved one? What type of support are you looking for? This can include disordered eating, eating disorders, body image support, meal time support, general nutrition counseling, etc.

What is your general availability for appointments?

Make peace with food, movement, and your body today.

Let’s work together

Make peace with food, movement, and your body today.

You belong here. ♡