New Patient Contact Form Type of visit * Disordered Eating/Eating Disorder Counseling Food Positivity/Body Image/General Nutrition Counseling I'm not sure which category I would fit into! Name * First Name Last Name Email * Phone number * (###) ### #### Guardian names, phone numbers and emails (only required if patient is under 18 years old) Date of birth * MM DD YYYY Why are you seeking nutrition counseling? * Share as much or as little information as you'd like! Have you been officially diagnosed with an eating disorder? If yes, what have you been diagnosed with and when? General availability for visits * Include days of the week and times Have you ever been a patient for Faithful Bites Nutrition? * No Yes Unsure What is your preferred method of contact? * I will use this method to contact you initially! Email Phone call Text Please allow for up to 24-28 hours to hear back from us. Thank you! Contact Info Phone: 331-333-0397Email: natalie@faithfulbitesnutrition.com
