Center for Nutrition Request for Services

Contact Information
Yes
No
Phone
Email

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

Reason(s) for Service Request
Adapting to Campus Dining Food Allergy Eating Healthy
Lactose Intolerance Meal Planning Guidelines Sports Nutrition
Weight Management High Blood Pressure High Cholesterol
Reflux
Your current or past medical conditions

Please list any current or past medical conditions:

Your current medications

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

Scheduling an Appointment

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

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

Disclaimer Statement

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.

Accept Decline

Submit
 
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Download a Paper Form

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Not interested in filling out the online form?

Don't worry. Download the paper version and mail it to the Center for Nutrition in Henderson Hall on campus.

Download a paper application here.