Get in TouchNew Client RequestsSpeaker & Presentation RequestsNew Client RequestsPlease enable JavaScript in your browser to complete this form.Are you completing this form for someone else (ex: a child or minor under the age of 18)? *YesNoName of the person completing this form: *What is your relationship to the client? *Please select an optionParentLegal guardian (other than parent)ProviderOtherEmail (of parent or guardian) *Phone # (of parent or guardian) *Client's Name *FirstLastClient Date of Birth *What state do you live in (to ensure the RD is licensed to practice in your state)? *TexasOklahomaOtherEmail *Phone #: *How do you prefer we reach out to you? *EmailTextPhone callIs there a specific dietitian you are interested in working with? *Open to any dietitianAmy WilliamsonAshley YunkerNikki ShawnWhitney LongHayley SandersI'm looking to work with a dietitian for (select all that apply): *Eating disorder recoveryDisordered eating / chronic dietingIntuitive EatingImproving my relationship with foodBody imageOther medical issue (ex: diabetes, IBS, heart disease, etc.)Weight loss (***as anti-diet dietitians, we do not set intentional weight loss goals or assist with weight loss diets)Do you plan to use health insurance coverage for your nutrition sessions? *YesNoWhich of the following health insurance plans do you currently have?Please select an option…BCBSUHCCignaAetnaAmbetterPlease note we are NOT in-network with any other insurance companies at this time.How did you hear about us? *Please select an option…TherapistPhysician / Medical ProviderTreatment centerFriend/familyInsuranceInternet searchOtherProvider's name: *Please share any additional information that might be helpful for us to know: *SubmitSpeaker & Presentation RequestsPlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Preferred Contact Method *EmailTextPhone callAbout Your RequestTell us a bit about the type of presentation you are interested in: *Preferred presentation date *DateTimeAlternative presentation date *DateTimeWho is the intended audience? Please choose all that apply. *High school athletesCollegiate athletesParents and/or familiesDance studioEating disorder professionalsOther professionals (not eating disorder related)Adult athletesVirtual conferenceIn-person conferenceOtherTell us more about the audience you are interested in us presenting to: *Thank you so much for your interest! Please allow 2-3 business days for a response.Submit
