CLIENT DIETARY ASSESSMENT FORM

THE COOKING COLLABORATIVE, LLC

CLIENT DIETARY ASSESSMENT FORM
To better understand your current & desired eating habits please fill out this form to the best of your ability to be reviewed by our team of chefs. Please feel free to omit any questions that are not applicable.
CLIENT'S NAME:*

First NameLast Name
CLIENT'S EMAIL:*
example@example.com
CLIENT'S PHONE NUMBER:*

Area CodePhone Number
CLIENT'S ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COMMUNITY GATE ACCESS CODE:
PROPERTY ACCESS CODE:
SPOUSE'S/PARTNER'S NAME:

First NameLast Name
SPOUSE'S/PARTNER'S EMAIL:*
example@example.com
SPOUSE'S/PARTNER'S PHONE NUMBER:*

Area CodePhone Number
CHILDREN'S NAMES & AGES (IF LIVING WITH YOU)
HOW MANY ADULTS WILL BE EATING THESE MEALS?*
HOW MANY CHILDREN WILL BE EATING THESE MEALS?*
WHICH MEALS WILL YOU BE REQUIRING?*

BreakfastLunchDinnerSnacksDessert
HOW OFTEN WILL YOU REQUIRE SERVICES?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

How invested are you in a chef?

	1	2	3	4	5

1 is testing the idea out, 5 is we're very serious!

DO YOU HAVE SPECIFIC GOALS WITH HIRING A NUTRIENT-DENSE SPECIALTY CHEF?*
**We recommend using the SMART goal setting theory for behavior change with our clients (specific, measurable, achievable, realistic, timely.) We are happy to assist with determining your goals!**
Do you have a specific budget in mind to spend per week?*
CURRENT STRUGGLES IDENTIFIED=IMPROVED BEHAVIORS. PLEASE LIST STRUGGLES.*
EXAMPLES INCLUDE: I snack at night on unhealthy foods. I notice portion control is an issue for me. I'm not sure I'm getting enough protein. I lack a well-balanced relationship with food. I'm having trouble drinking enough water. I want a quick-fix and am impatient with bloodwork changes and/or weight loss.
COMMON CLIENT GOALS - PLEASE SELECT ALL THAT APPLY.*

Learn & eat a healthier, more balanced earth-foods diet (natural/minimally processed/local)Lose weight through healthy eating & lifestyle changes.Improve flagged blood work through healthy eating & lifestyle changes.Eat locally & consciously-sourced ingredients for improved nutrient-density.
FOOD ALLERGIES:*

PeanutsFish/ShellfishEggsSesamePeanut or nut butterSoy productsMilkTree nuts (Walnuts, almonds, pecans etc.)MushroomsGlutenMast Cell Activation Syndrome - *Please alert Chef Dee for further paperwork*We do not have any food allergies in our household.Other
INDIVIDUAL/S NAME WITH ALLERGIES:
PLEASE PROVIDE ANY ADDITIONAL INFORMATION NOT COVERED ABOVE:
WOULD YOU LIKE TO HAVE A 20 MINUTE CALL TO REVIEW ALLERGEN SAFETY PROTOCOL IN YOUR HOME?

YESNO
TYPES OF CUISINES MOST ENJOYED:*
EXAMPLES INCLUDE: Italian, Thai, Mediterranean, Middle Eastern, Peruvian, Etc.
DO YOU ENJOY/EAT FREQUENTLY:

Salads as a main course (lunches)Fresh low sugar juicesSmoothies as a snackStrong, bold flavors (Middle Eastern/Indian/Thai Seasonings/etc)
FOODS NOT CONSUMED:*

No Red MeatNo ChickenNo FishNo ShellfishNo EggsNo PorkNo Dairy ProductsWe Eat Everything!Other
FAVORITE RESTAURANT NAMES IN YOUR CITY:
EXAMPLES INCLUDE: Italian, Thai, Mediterranean, Middle Eastern, Peruvian, Etc.
ANY ADDITIONAL INFORMATION IN REGARDS TO PRODUCTS YOUR FAMILY AVOIDS:
EXAMPLES INCLUDE: "We do not like plastic. We avoid canned products, We try to limit our gluten intake."
DO YOU OWN ANY OF THE FOLLOWING:

Food ProcessorCutting BoardsSheet Trays/Baking TraysGlass Storage Containers (enough for meal prep)Gas StovetopVitamixIce Cream MakerKitchenAid MixerSlow Cooker/Pressure CookerJuicer
PLEASE SELECT A TIME FOR A 30 MINUTE CALL IF DESIRED (SERIOUS APPLICANTS)
COVID-19: If you have specific safety protocols you would like for our chefs to follow in your home, please advise below. We agree to alert the client if covid-19 is contracted.
*PLEASE NOTE WE REQUEST THAT CLIENTS NOTIFY US OF COVID-19 CONTRACTION.*
I understand The Cooking Collaborative is a chef agency & chefs work a minimum of 2-3 additional hours outside the clients in-home service hours to render the best service possible (shopping/sourcing/menu creation.) Pricing is determined based on the above details. Prices are variable based on each chefs desired rate.
I understand that the client contract agreement must be signed prior to services being rendered.

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THE COOKING COLLABORATIVE, LLC