Download Forms
NEW PATIENTS: Prior to a consultation in my office, please print the New Patient Intake Form, fill it out and bring it in with you. If you are unable to download and print these forms, please call me and I will provide you with one! Click right on one of the links to open the form or save it to your computer.
New Patient Intake Form (Word Document) . New Patient Intake Form (Acrobat .pdf)
Food Frequency Checklist (Word Document)
Release of Information Form
3-Day Food Journal
Out of desperation, I decided to see a nutritionist. I felt that I was eating responsibly i.e.: healthy foods, portion control, vitamin supplements and yet gaining weight 2-3 pounds a week with chronic heartburn. Diane helped me immensely with surprisingly few changes. Within three visits I lost 15 pounds and have NO heartburn, sleep better and feel more energized. These benefits have changed my life and I am so grateful. Kate T.
Policies
PAYMENT
Payment is expected at the time of your appointment. This practice is a fee-for-service or self pay. Payment will be in the form of cash or checks made payable to Northeast Nutrition. Gift certificates are available.
MEDICAL INSURANCE
Medical insurance companies may or may not offer coverage for medical nutrition therapy or preventative care. Carefully investigate the type of coverage you have. It is your responsibility to pay for your visit and to have your insurance company reimburse you if applicable. You will be provided with a receipt that you can submit to your insurance company for reimbursement. You will be responsible to submit claims directly to your carrier.
APPOINTMENTS and CANCELLATIONS
Appointments are made to focus on your concerns in a timely manner. Please complete the Northeast Nutrition Client Assessment Form prior to your arrival. The forms can be mailed or downloaded from www.Tryon-Nutrition.com. You will be charged for missed appointments unless you notify me 24 hours in advance, or in cases of emergency.
CONFIDENTIALITY
All information disclosed is confidential. A signed Release of Information will be obtained and kept on file when necessary to correspond with your doctor.
FEES
Fees for individual counseling have set fees for an initial assessment visit and follow-up visits. Fees for consulting or contract work will be reviewed individually based on the project’s requirements.
DIETETICS definition:
"Dietetics or nutrition practice" means the integration and application of the principles derived from the sciences of nutrition, biochemistry, food, physiology, and behavioral and social sciences to provide nutrition services that include:
(A) Nutrition assessment; (B) the establishment of priorities, goals, and objectives that meet nutrition needs;
(C) the provision of nutrition counseling in health and disease; (D) the development, implementation and management of nutrition care plans; and (E) the evaluation and maintenance of appropriate standards of quality in food and nutrition.
After years of struggling with weight related problems Diane has supplied me with the tools to succeed. With her guidance not only do I understand healthier eating but I can enjoy healthy eating. Working with Diane has been a lifestyle change that has been all positive. Thank you Diane! James H.
Helpful Links
ECRC Physical Therapy - http://www.ecrc-pt.com NIA Connecticut - http://www.nia-connecticut.com United States Department of Agriculture - http://www.mypyramid.gov/ American Dietetic Association - http://www.eatright.org/ The Calorie Control Council - http://www.caloriecontrol.org/ Free Diet Plans - http://www.sparkpeople.com/ |
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Diane has helped me to change my eating habits and slowly and steadily lose weight and keep it off. She is knowledgeable and personable and easy to talk to. Diane has showed me how to use simple tools and strategies to help me to lose over 30 lbs. Christopher O.