Thank you for becoming a new client. Please fill out the form below prior to your first appointment.

Name *
Date of Birth *
Date of Birth
Please enter your birthdate
Have you ever been diagnosed with an eating disorder?
Do you take vitamins/supplements?
Check any foods below you do not eat
Which types of alcohol (if any) do you consume?
Do you smoke or use tobacco or nicotine products?
Do you feel stressed?
If you do feel stressed, at what level would you rate your stress?