The Aliveness Project Medical Nutrition Therapy Referral

Aliveness Project Medical Nutrition Therapy Referral
New referrals to Aliveness Project's Medical Nutrition Therapy (MNT) Program, including Oral Nutrition Supplements ("ONS" such as Ensure, Boost, etc.) are currently on waitlist due to limited Federal and State Funding.

Please contact Teal Walters, RDN, LD, CNM directly at teal@aliveness.org or 612-367-6257 to:
- See if a client/patient is eligible to be added to the waitlist and receive a referral form.
- Request Open Arms application assistance (Aliveness RDs will continue to complete Open Arms referrals and renewals for all Aliveness members).
- Receive alternative non-Ryan White billed Dietitian/nutrition resources.
- For all other program questions including advocacy opportunites to ensure this service continues to be offered to Minnesotans living with HIV.
Please note: Aliveness membership and active Program HH is required for MNT services as it allows Aliveness to follow Ryan White MNT Standards.

Aliveness membership application: https://form.jotform.com/202324952678057
Name of Member*

First NameLast Name
Member Date of Birth*
NoYes (insert language below)
Language:
She/HerHe/HimThey/ThemAll or any pronounsMixed pronouns (specify below)Other (specify below)
Mixed/Other Pronouns:
Member Number (if known)
Email (if available)
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone call (with voicemail)Phone call (without voicemail)EmailText
Nutritional supplements (without diabetes)Nutritional supplements (with diabetes: type 1, type 2, prediabetes, gestational diabetes)Open Arms referral in addition to one of the above
Currently (or in the past 6 months) prescribed nutritional supplements (i.e. Ensure, Boost, Glucerna)A physician has expressed concern about being underweight/needing to gain weightChronic nausea or vomiting (2+ weeks)Chronic low appetite (1+ month)Recent unintentional weight lossEating 50% of usual food intake (2+ weeks)Diabetes (Type 1 or 2)Gastrointestinal disorder (i.e. IBS, Crohn's, GI cancer)Current or recent cancerKidney disease (with or without dialysis)None of the aboveOther (list in medical conditions below)
Current Height
Current Weight (& estimated date taken)
If recently lost weight without trying, please include the amount lost and timeframe (example: 5 pounds in 2 months)
Medical conditions known
PrivateMedicareMedicaidOther
YesNoUnsure
Last HIV Appointment
CD4 Labs & Date
Viral Load & Date
Pharmacy (and city pharmacy is located)*
Eating Disorder Screening for Primary Care (ESP)

The below questions are included to ensure that the appropriate care model and therapy is provided. The answers to the questionnaire will not diagnose an eating disorder, nor deem the member ineligible for MNT.
YesNoMember not present
YesNoMember not present
YesNoMember not present
YesNoMember not present
YesNoMember not present
YesNoMember not present
Name & Phone/Email of Referring Person*

Aliveness Project Medical Nutrition Therapy Referral

Eating Disorder Screening for Primary Care (ESP)

Medical Records

Release of Information