First Name
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Last Name
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Preferred Name
Gender
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Preferred Pro-nouns
Age
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What city/state do you live in?
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Phone Number
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(###)
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Email Address
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How did you hear about me? (Instagram, Tik Tok, etc.)
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What is your Instagram handle? For example, mine is @theguacwarddietitian (please double check that this is correct!)
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Preferred method of contact
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(This is how I will be reaching out to you to discuss next steps!)
Bariatric surgery procedure and date you had it (IE - RNY 6/1/2025)
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Did you see a dietitian before or after surgery? If so, what has your experience been like?
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With as much detail as possible: what is the main reason you are reaching out to work with me? (Specify any nutrition related struggles)
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Depending on the state you live in, your insurance may cover some sessions! I accept BCBS, Aetna, Cigna, UHC and Mass General Brigham Health Plan. If interested in checking your coverage for my services, please list your insurance plan
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If not using your insurance coverage, my services start at $297 per month. Are you prepared to make this investment?
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Is there anything else you'd like me to know?
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