Form

First Name*

Last Name*

Email*

Phone number*

Date of birth*

State/Region*

As in where do you currently live?

How did you hear about Clarified Nutrition? If someone referred you, please let me know who :)*

Please briefly list (in order of importance to you) your top 3 health goals here:*

If you want more energy, regular periods, consistent BMs, less anxiety about food and to feel better in your body I GOT YOU!
If your number one goal is weight loss, I'm probably not your person. Read more about how I approach weight in my practice here.

Tell me more! In a few sentences, tell me about your health concerns:*

What is your biggest struggle/what is most frustrating about dealing with these symptoms or health concerns?*

What have you tried so far to resolve these concerns?*

Why do you think you haven't been able to reach your health goals on your own?*

If you could wave a magic wand and transform your health, what would it look like in 4 months? What about in 12 months? Get specific!*

On a scale of 1-10, how important is it for you to fix these problems right now*

Do you believe you can resolve your health concerns and start feeling better?*

Are you only interested in what insurance may cover or would you be interested in participating in a more comprehensive program that maximizes your chance of success but will not be fully covered by insurance?*

Please note Claire is in-network with Anthem/Blue Cross Blue Shield, Cigna, and United only at this time. Coverage of nutrition services varies by plan. Our billing team can help you check benefits after you've scheduled an appointment and we recommend you verify insurance coverage as well.

Whatever it takes to feel better fastest!

No, I'm only interested in what my insurance will cover at this time.

I'm not sure, I need more information to decide