Please Acknowledge The Following: It is our policy that you will be committing to a minimum of 3 months of care with your Registered Dietitian.
The cost of our membership plans are transparent on the “Membership” page of our website. Financial commitment is agreed upon the discovery call.
I have read the terms of our services, including billing and insurance questions*
Root Health Nutrition and Wellness does NOT verify insurance benefits for patients' sessions. We may not participate in your insurance and/or the reason for the visit may not be cover
Specialized testing may be recommended by your RD. It is your choice to decide if you would like to proceed with testing. Costs may vary and will NOT be covered by insurance.
I am aware of our cancellation policy (as read on the website) and ready for a commitment to my or my childs care.
Which statement best describes you/ your child? I have a specific condition and am looking for a functional medicine approach.
I am generally well, I am looking to optimize my health.
I am seeking an alternative approach for disordered eating. I am aware of the required commitment and monthly fee for this type of care.
How willing are you to do the following? (5 being the highest)
What are you/ your child's health goals? Improve Sleep or Insomnia
Identify Food Allergies / Sensivitites
Decrease Stress, Regulate Mood
Improve ADD / ADHD, OCD, or PANS/ PANDAS
Overcome sensory challenges/selective eating/increase variety in diet
Optimize Fertility & Prenatal Care
Optimize Athletic Performance
Improve My Relationship With Food
Reduce Pain & Manage Inflammation
Eating Disorder Treatment
Lose Weight or Gain Weight
Improve Thyroid Health, Hypothyroidism, or Hashimoto's Thyroiditis
Manage Digestive Function, IBS or IBD Conditions
Improve Type 1/2 Diabetes or Prediabetes
Check off all conditions/ symptoms that apply: Neurological, behavior or speech challenges
Chronic pain / inflammation
Anxiety around food or selective eating
Skin conditions / issues (hives, ezcema, psorasis)
Abnormal thyroid function
Cardiovascular health (blood pressure, cholesterol, fatty liver).
Anxiety and/or depression
Hormonal issues (PCOS, endometriosis, infertility, etc.)
Poor immunity / chronic illness
Head Injury (TBI, seizures, concussion)
Mid-day crashes / cravings
Indigestion, bloat, constipation, diarrhea, etc.
Chronic fatigue / sleepyness
Please describe your top health concerns:
What have you or your child tried before?
What alternative approaches are you looking for?
If referred, please share who you were referred by:
Do you have insurance? If so, which provider?
Please fill out the information below and we will be in touch with you to start your journey! Which days work best for your call?
Which hours are best to contact you?
Submit Application
Thanks for your interest in becoming a patient! We'll get back to you soon after reviewing your application.
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