Client Registration Form

Client Details:
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
E-mail *
example@example.com
I work with clients who can be open to a HAES (Healthy At Every Size) and non weight centric approach. I don't focus on weight loss. If you are looking to (re)build a healthy relationship with food and find a way of eating that works for you individually, then this is for you.

Sessions are all virtual (or over the phone) and last about an hour. I charge $155/per session, which includes sales tax. You can choose how many sessions you would like, though I highly suggest at least 2.
What are you hoping to get out of counseling: *
Have you been diagnosed currently with an eating disorder? *

Yes No
Are you open to counseling through a non weight centric approach *
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Client Details: