Home / Register Counseling Registration You don’t have JavaScript enabled. Please enable JavaScript in your browser settings and try link again. BU Faculty & Staff Counseling Registration Form * = mandatory field First Name: * Last Name: * Gender: Please select Male Female Other BUID ID: * U DOB: * Email: * Primary Phone: * Secondary Phone: Current Address Street: * City: * State: * Please Select: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: * The SCNC offers a unique Risk Factor Management Package as part of BU’s health and wellness program. The package is designed for BU employees with cardiac risk factors such as a Body Mass Index of 25 or higher, diabetes or prediabetes, and elevated blood pressure or cholesterol. Please indicate all nutrition concerns below. Nutrition Concerns (check all that apply): * Healthy meal planning Healthy weight loss Sports nutrition Stress over/undereating Emotional over/undereating Social over/undereating Hunger management Unhealthy weight control practices Eating disorder (Check all that apply) Anorexia Nervosa Bulimia Nervosa Binge eating disorder Other Eating Disorder Food allergies or intolerances (Check all that apply) Wheat Milk Peanuts Tree nuts Eggs Shellfish Soy Fish Lactose intolerance Gluten intolerance FODMAPs Other: If other allegy or intolerance, please describe: Gastrointestinal disorder (Check all that apply) IBS Crohn’s Disease Ulcerative Colitis GERD Celiac Disease Other: If other gastrointestinal disorder, please describe: High blood pressure High cholesterol Diabetes/Pre-diabetes Vegetarian/vegan Iron-deficiency anemia Polycystic ovary syndrome Bariatric surgery Other: If other reason for visit, please describe: No nutrition concern Additional information you would like to share:
