New Client Nutrition Counseling Questionnaire
Meagan Gibson, MS, RDN, LDN, CD
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Why are you interested in seeing a Registered Dietitan?
*
Please indicate which nutrition counseling service you are interested in:
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General Nutrition Counseling
Intuitive Eating Counseling
Other
What are your current health and nutrition goals? Please describe below:
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Tell me your "why"? Why are these your current goals?
What do you believe your biggest challenges are that are preventing you from reaching your goals?
How would you rate your readiness to make changes and achieve these goals, on a scale from 1-5?
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1 = I have not thought about making changes to achieve my health goals and I am not ready to
2 = I have thought about making changes, but I am unsure if I am ready to
3 = I am somewhat ready to make changes
4 = I am 100% ready to make changes today
5 = I need support maintaining the changes I have already made
Are you currently ready to make a financial investment to join a nutrition counseling program?
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Yes
Not at this time
Not sure
My monthly budget for nutrition counseling is:
*
This will help me determine an appropriate starting point for your program. If you're interested in short-term guidance, please visit my website and complete the Nutrition Consult Inquiry Form.
Anything else you'd like to share with me?
Please verify that you are human
*
Submit Survey
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