Holistic Nutrition Consulting Application

Holistic Nutrition Consulting Application

Complete this application to help us understand your health goals.
Contact Information
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Age
How did you hear about Selin?
Your Goals
What is your primary health goal right now?
Examples: lose 15 lbs, improve energy, balance hormones, reduce digestive symptoms. Please be specific and include measurable targets if possible.
How long have you been navigating this issue?
Examples: weeks, months, or years (e.g., 6 months, 2 years).
What have you already tried to address this issue? What worked and didn't work?
Examples: working with a doctor and/or naturopath, seeing a dietician, calorie counting, elimination diet, supplements, therapy, medications. Please be specific about duration and adherence.
Why are you seeking support now instead of waiting longer?
Examples: recent diagnosis, pregnancy planning, plateaued progress, worsening symptoms. Please be specific about triggers or timing.
Health Background
Please list any diagnosed medical conditions
Examples: hypothyroidism, PCOS, IBS, diabetes. Include diagnosis date if known.
Please list your current medications and supplements:
Examples: metformin 500mg daily; fish oil 1000mg daily; vitamin D 2000 IU. Include dose and how long you have taken them.
Readiness & Commitment
What obstacles have prevented you from achieving your goal so far? And what do you feel you need most support with right now?
Examples: lack of time for meal prep, emotional eating, limited budget, family schedule. Please be specific and give examples.
How committed are you to implementing recommendations and making changes?

1

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10

1 is Not committed, 10 is Fully committed
What would happen if nothing changed over the next year?
Examples: continue weight gain, persistent fatigue, worse digestive issues, no progress toward health goals. Be specific about likely consequences.
Agreement
I understand that Selin is a holistic nutritionist; her services are educational in nature and do not replace medical care.
I confirm that the information I have provided is accurate to the best of my knowledge.
Signature
Date

MonthDayYear
Date
How Sessions Work
Selin's approach focuses on practical, sustainable nutrition and lifestyle strategies tailored to your goals, preferences, and daily life.
What's Included Depending on your service package, offerings may include:

• Comprehensive nutrition assessment • Review of health history and current concerns • Personalized nutrition recommendations • Written action plan • Goal setting and progress tracking • Educational resources and handouts
What Is Not Included Please note that Selin’s work is educational in nature. Selin does not:

• Diagnose medical conditions • Prescribe medications • Replace your physician or healthcare team • Provide emergency medical care • Guarantee specific outcomes or results Any recommendations are intended to support overall health and wellness and should not replace individualized medical advice.
Fees
All appointments are conducted virtually via video conferencing. Sessions are designed to provide clarity, direction, and structured support at whatever stage you are at.

A Discovery Consultation (30 minutes) is $60 + GST and is intended to clarify your main concern, determine fit, and outline next steps.

An Initial Consultation (60 minutes) is $175 + GST and includes a comprehensive review of your health history, symptoms, lifestyle, and goals, followed by a personalized nutrition strategy.

Follow-Up Sessions (30 minutes) are $80 + GST and are used for ongoing support, progress review, and refinement of your plan.

The 3-Session Package is $425 + GST and includes one Initial Consultation plus two Follow-Up Sessions, providing structured continuity, accountability, and adjustment over time.

Health spending accounts may cover the cost depending on your insurance plan, and it is your responsibility to confirm coverage and submit any claims.
Next Steps
Once your application has been submitted, Selin or a member of the team will review your information and reach out to schedule your appointment. If you are unsure which option is best for you, a Discovery Consultation is a great place to start. Should you choose to continue with a longer consultation or service package, the fee paid for your Discovery Consultation will be credited toward your Initial Consultation or package purchase. Please allow 1–3 business days for a response regarding scheduling and next steps. We look forward to serving you!
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Holistic Nutrition Consulting Application

Contact Information

Your Goals

Health Background

Readiness & Commitment

Agreement

How Sessions Work

Fees

Next Steps