Home / Register Counseling Registration You don’t have JavaScript enabled. Please enable JavaScript in your browser settings and try link again. General Public Counseling Registration Form * = mandatory field First Name: * Last Name: * Gender: Please select Male Female Other 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: * Who referred you to us?: Self Primary Care Physician Behavioral Medicine provider Coach/Athletic Trainer Friend Treatment Center Other: If referred by other, who?: 1. Please select the option below that best reflects the PRIMARY reason for your visit so that we can schedule you with the appropriate provider. You may select additional reasons for your visit in the next section: * Healthy meal planning Concern about weight gain in college Healthy weight loss Sports nutrition Stress over/undereating Emotional over/undereating Social over/undereating Dining hall 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 primary reason for visit, please describe: 2. Please select any secondary reason(s) for your appointment (check all that apply): * Healthy meal planning Concern about weight gain in college Healthy weight loss Sports nutrition Stress over/undereating Emotional over/undereating Social over/undereating Dining hall 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 secondary reason Additional information you would like to share: Primary Insurance The SCNC Registered Dietitian Nutritionists are providers for many of the major insurance companies, however insurance coverage for nutrition services varies greatly depending on policy type and medical diagnosis. Please check with your insurance company to determine if Medical Nutrition Therapy is a covered health benefit for you. You will be responsible for any balance not covered by insurance. Insurance Company * Aetna Aetna Student Health Harvard Pilgrim Health Care Blue Cross Blue Shield of Massachusetts Tufts Health Plan United Healthcare Other: Name of Insurance: Self Pay Insurance ID#: Group#: Primary Insured: Self Spouse Parent Other Information of Primary Insured (if not self) Name: Date of Birth: Street Address: 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:
