client intake form

Please provide as much information as possible in this intake form. Having this information allows us to get off to great start. This form should take about 15-20 minutes to complete. 

 
Please fill out this health questionnaire as best as you can. If there are questions you don't understand or prefer to not answer, we can discuss them during our first meeting. This form should take you about 10-15 minutes to complete.  

We realize there are a bunch of questions. Each one is important for us. The info helps us to get to know your body, which will assist in steering our recommendations. 

Thank you very much for taking the time to answer honestly and completely.
 
 
 
General Information
 
 
Lifestyle Information
 
 
 
Health Information
 
 

Please indicate any of the following that apply to you or anyone in your immediate family:

 

 
 
Nutrition Information
 
 
 
 
 
 
 
 
Check all of the following that apply to you:
 
 
 
 
Women's Health (skip this section if you're male)
 
Please check all that apply to you:
 
 
 
 
 
Office Policies Acknowledgement

 

Fees:

  • The initial nutrition visit is $150 per hour (or package price) and includes diet analysis and consultation. 
  • Follow-up sessions are 1 hour ($150) OR ½ hour ($95) (or package price).
  • Session fees are paid directly to Healthy Nest Nutrition, LLC.
  • Payment is due at time of service unless prior arrangements have been made. 
  • Payment can be made by cash or check or credit card.
  • There will be a $25.00 charge for all returned checks. 

Packages:

  • Prepaid packages are discounted from individual session prices
  • Prepaid packages are non-refundable
  • Program packages are a combination of sessions, are discounted off individual sessions, and are available for hour-long, ½ hours & a combination, depending on the particular package.

 

Insurance:

  • Healthy Nest Nutrition does not accept insurance, but can use most health care flex spending account money for nutrition services

Missed Appointments:

  • A 24-hour notice for cancellations is required for missed sessions.
  • Late appointments will not be extended and the fee for the original session will be charged.
  • No-show sessions will be charged at full price 

Medical Grade Supplements:

  • All supplements must be paid for at time of purchase.
  • Unopened supplements can be returned for full refund within 60 days of purchase. 
  • Supplements are not included in the session fees.
 
 
Agreement & Release
 

Read the following statement and initial below:

understand that Healthy Nest Nutrition, LLC (Healthy Nest Nutrition) will provide me with professional nutritional evaluation, therapy, and support for the purpose of enhancing my health (Nutrition Therapy).  I understand that Nutrition Therapy is not intended as a diagnosis, treatment, prescription or cure for any disease, mental or physical, and is not intended as a substitute for regular medical care. In Nutrition Therapy there are no medical procedures performed and medications are not prescribed.    

I understand that Nutrition Therapy services will be provided by Robin Hutchinson who is a Master Nutrition Therapist and has completed two years of schooling at The Nutrition Therapy Institute, an accredited Nutrition Therapy College.  I understand Robin Hutchinson is not a physician licensed pursuant to Article 36 of C.R.S. Title 12, nor licensed, certified, or registered by the State of Colorado as a health care professional and I should discuss any recommendations made by Healthy Nest Nutrition with my primary care physician, obstetrician, gynecologist, oncologist, cardiologist, pediatrician or other board-certified physician.  

I release Healthy Nest Nutrition from any liability for my health issues.   I have truthfully completed the Client Intake Form for Healthy Nest Nutrition and listed all my known physical and medical conditions, as well as any medications and supplements that I am taking and I will keep Healthy Nest Nutrition informed of any changes.  I agree to pay Healthy Nest Nutrition's rates, which are outlined in the attached fee schedule.  Healthy Nest Nutrition does not accept health care insurance.  Healthy Nest Nutrition is covered by liability insurance applicable to any injury caused by an act or omission by its provision of alternative health care services.    

This agreement and release is being signed voluntarily and not under duress of any kind.

 
by signing below, I agree that all the information I have provided is true.
 

we look forward to working with you!