Nutritional Assessment Request

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Contact Information

Contact Information

Emergency Contact

Emergency Contact

Preferred day(s) to meet (Please check all that apply)

Preferred day(s) to meet (Please check all that apply)
Preferred time to meet:
Preferred time to meet:

 Reason for wanting to meet with Nutrition Advisor:

Weight and Height Information

Weight and Height Information
Past medical history or chronic disease:
Medications, Vitamins, Minerals and/or Supplements:
Prior nutritional education:
GOALS AND EXPECTATIONS
What is your level of physical activity:
How do you sleep:
Food allergies or intolerances:
Food avoidances:
Individual Nutrition Counseling
(Ages 12 & up) One-on-one nutrition counseling with a certified nutrition consultant that will be tailored to the individual needs, providing education and guidance such as weight management, diabetic education and meal planning, basic sports nutrition, and heart healthy nutrition.
First session is 60-minutes. Follow-up sessions are 30 minutes.

Cost per session:
$60.00 60-minute initial consultation
$35.00 30-minute follow up consultation

Refund Policy:

*All services are available by appointment only.
*There are no discounts on the cost of any services unless authorized by the Fitness Manager.
*Clients must pay for all services in advance.
*Sessions are approximately 30-60 minutes.
*To cancel a nutrition session, YOU MUST CONTACT YOUR NUTRITION CONSULTANT DIRECTLY WITHIN 24 HOURS of your scheduled session.
*Clients who arrive more than 15 minutes late will be charged for the session.  In addition, the Nutritional Advisor may cancel the session.
*Nutrition Assessment fees are subject to change



By hitting the "submit" button below, you agree to the above training and refund policies.

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