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Functional Nutrition Client Inquire Form

LIFE EDIT NUTRITION BY DARLENE REGUEIRO, RDN

WELCOME!

This application will take you approximately 5 minutes to complete.

Please fill out this application if you’re considering working together. It will help us get to know you better before our free discovery call, where we’ll discuss a personalized game plan and the services available for you.

First Name*

Last Name*

Email*

Phone Number*

State/Region*

Where you currently live

Date of birth*

Briefly describe your biggest nutrition and health concern and list your top 3 health goals (in order of importance to you).*

Ex: 1. Control Craving 2. Manage PCOS 3. Improve fertility

What have you tried in the past to address your nutrition and health concerns, and what has been the most frustrating aspect in your efforts?*

If you could wave a magic wand and create your dream lifestyle, what would it look like? How would you feel? *

What Are You Interested In?

💡 I just want to use only what my insurance will cover – I’m not interested in investing beyond that. This is a great option if you just need basic nutrition support (what and when to eat). However, if you have hormonal imbalances, gut issues, weight struggles, or symptoms that need deeper answers, this is only a starting point—you’re likely a candidate for Functional Nutrition Coaching, where we use lab testing to uncover the root cause and create a truly personalized plan.

🔥 I WANT IT ALL! – I’m ready to invest in the Functional Nutrition Program, including testing, a customized protocol, sessions, messenger support between sessions, expert guidance, and a plan to fix my imbalances at the root. I understand this is an out-of-pocket investment, and I’m excited to commit to my health!

🔬 I’m curious about my body & want testing only – I’d like to purchase functional lab tests and see my results, but I’ll decide later if I need a plan.

Our 1:1 Functional Nutrition Coaching Program is for those who are ready to prioritize their wellness and take a deep dive into their health.

✔️ Investment starts at $2,500, which includes:

1:1 coaching sessions
Functional lab testing (HTMA, GI-MAP, DUTCH Test options available)
A personalized protocol & expert guidance
Messenger support between sessions
📌 Insurance Coverage: If your plan covers nutrition sessions, you can use your benefits to offset consultation costs. However, functional lab testing is always an out-of-pocket expense.

💳 We accept the following payment methods:
✔️ Credit/debit cards
✔️ HSA/FSA payments
✔️ Financing through Affirm (monthly payments as low as $185!)

🔹 Would you like to proceed?*

Please note that our program is an out-of-pocket expense. We accept payments online via credit/debit card, HSAs, and FSAs.

How did you hear about me? If someone referred you, please list their name