Name *

First Name

Last Name

Phone *

(###)

###

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What kind of support are you seeking? *

Please check all that apply

Eating disorder recovery/treatment

Recovery from chronic dieting

Intuitive eating support

Assessment for disordered eating

Body image concerns

Weight inclusive and/or ED informed diabetes care or education

New diabetes diagnosis

Diabetes education and support

Acknowledgement of out of network status *

Please check this box indicating that you understand we are not in-network with any insurance providers. Clients pay us up front for sessions and we can provide superbills that clients can independently submit to their insurance company for out-of-network reimbursement if they have out-of-network benefits. Please note that a superbill does not guarantee reimbursement for services. Please let us know if you would like more information on how to determine if services will be covered, we can provide you with a script to use when talking with your insurance company. We do hold a few spots for sliding scale sessions, please note in the above section if this is something you would need in order to access care.