Get in Touch with Our Team

Guardian's Name *

First Name

Last Name

Guardian's Phone *

(###)

###

####

Minor's Name *

First Name

Last Name

Minor's Phone (If applicable)

(###)

###

####

Minor's Date of Birth *

MM

DD

YYYY

Preferred contact for Discovery Call information: *

Guardian email

Minor email

Both

What service(s) are you interested in? *

Insurance based nutrition counseling

Out of pocket nutrition counseling

Out of pocket virtual meal support group

Out of pocket virtual individual meal support sessions

Does the minor have insurance? *

Yes

No

Does the minor have a treatment team? *

Yes

No

How would they like to be seen? (Please check all that apply) *

*Please note we are able to accommodate in person appointments at our offices in Manhattan and Watertown, New York.

In Person- NYC

In Person- Watertown

Virtual

What is their general availability? (Please check all that apply) *

Morning (9 am-12 pm)

Afternoon (12 pm-4 pm)

Evening (4 pm-6 pm)