Nutrition Center Request Form

Name:

Are you over 18?:

Yes
No

Campus Address:

Home Address:

Primary Phone:

Email:

Preferred Contact Method:

Phone
Email

Please Note: If selecting e-mail, this is not a secured communication method.

Adapting to Campus Dining	Food Allergy	Eating Healthy
Lactose Intolerance	Meal Planning Guidelines	Sports Nutrition
Weight Management	High Blood Pressure	High Cholesterol
Reflux

Other (specify):

Please list any current or past medical conditions:

Medical Condition/Problem and Date of Diagnosis

Please list any current medications, vitamins or other supplements you are taking:

Medications, vitamins, supplements currently taking and Amount

Appointments are available Tuesdays and Wednesdays between 9 a.m. to 5 p.m.

Preferred date/time for appointment (choose all that apply)

Tuesday (enter times):

Wednesday (enter times):

I understand that the Center for Nutritions nutrition counseling service is a training program and that nutrition counseling will be provided by Dietetic Interns under the supervision of a Registered Dietitian.

I understand that my relationship with my nutrition counselor is considered confidential and that the information will not be released without my written consent. I also understand that the issues that I am working on with my nutrition counselor might be discussed in supervisory sessions with the instructor and other dietetic interns but will not be attached to my name in any way. I understand that outcomes information may be collected for the purpose of student research but will not be attached to my name in any way.

I understand that concerns about suicide, homicide, harm to self or other and/or child abuse may place limitations on confidentiality.

I understand that I may terminate my involvement at any time by notifying my nutrition counselor (dietetic intern) or the Dietetic Internship Faculty.

I understand that after an initial in-person meeting I may elect to have contact with my nutrition counselor (dietetic intern) through electronic means such as e-mail and understand that this method of communication is not secure.

I attest that all information provided is true and accurate to the best of my knowledge.

Do you accept?:

Accept

Decline

Validate Image:

Submit