Name *

First Name

Last Name

Phone *

(###)

###

####

Your age *

*we currently work with adolescents age 15 and up

Under 18 (Virtual Sessions Only)

Over 18 (Virtual & In-Office Sessions)

Acknowledge that you have reviewed self pay pricing and insurance FAQs (located in 'Work Together') *

I understand my insurance is in-network [Med Mutual (dietitians & therapists), Cigna (dietitians only), UHC (therapists only)] and coverage of sessions varies by plan

I understand my insurance is out-of-network and I agree to self pay rates ($150-$175)

What kind of support are you seeking? (check all that apply) *

All support is provided through a weight-inclusive non-diet approach (weight loss not offered)

eating disorder recovery

body image concerns

Intuitive Eating

recovery from chronic dieting

management of a chronic condition (ex: diabetes, PCOS)

Which provider are you interested in working with? *

First available dietitian

First available therapist

Kristen Murray, dietitian (she/her)

Anne Godina, dietitian (she/her)

Julie Bogner, dietitian (she/her)

Lindsey Flannery, dietitian (she/her) *virtual appointments only

Hashina Akther, therapist (she/her)

Mari Ballas, therapist (she/her) *virtual appointments only

How would you like to be seen?

Select all that apply

Virtual/Telehealth

In-Office (Westlake OH)

What days/times of the week are you regularly available for sessions? *

Select all that apply

Monday 8a-12p

Monday 12p-3p

Tuesday 8a-12p

Tuesday 12p-4p

Tuesday 4-7p (virtual only)

Wednesday 8a-12p

Wednesday 12p-4p

Wednesday 4-7p (virtual only)

Thursday 8a-12p

Thursday 12p-4p

Friday 8a-12p

Friday 12p-2p