We Want to Hear from You!

We are inclusive, but we are not for everyone.

Client name

First Name

Last Name

Client's Date of Birth

MM

DD

YYYY

Email

Phone

(###)

###

####

I would like to start with a complimentary Discovery Call

I would like a phone call from Liz Brinkman, RD for a complimentary discovery call to have my questions answers over the phone.

I need help with:

Eating Disorder Recovery

Intuitive Eating

Nutrition Therapy for Chronic Condition (ex. Diabetes, IBS, High Cholesterol etc.)

Recovery from Chronic Dieting

Body Image Concerns

ADHD

Where are you located? (Note: We can only bill insurance if you are a resident of Arizona.)

What Insurance plan do you have?

Insurance Member ID and Group number (so we can verify insurance benefits for outpatient nutrition counseling.)

Provider-line Phone Number (on the back of your insurance card)

Referred by

Is There Anything Else We Should Know?

We are a team of HAES®-aligned, weight-inclusive clinicians who work 1:1 with people. We help people create supportive eating environments and meal/snack strategies to build a sense of curiosity and safety around eating. We do not prescribe weight loss diets.

For general questions and inquiries, please feel free to email us at hello@onthebrinknutrition.com

If you’re interested in working with a Registered Dietitian from our collective, please fill out the form and someone from our team will be in touch with you soon.

FAX
(480) 933-0036