Request appointment | Tidal Nutrition & Recovery

Inquiry reason

Referral source

Enter how you were referred to my services

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Do you currently have a Primary Care Physician (PCP)?

If yes, please provide their name, practice/clinic, and phone number below.

Yes No

PCP Name, Practice & Phone (if applicable):

Limited to 600 characters

Do you currently have a therapist and/or psychiatrist?

If yes, please provide their name, practice/clinic, and phone number below.

Yes No

Therapist / Psychiatrist Name, Practice & Phone (if applicable):

Limited to 600 characters

Is any other current provider actively managing your medical or psychiatric care related to eating, food, weight, or body image?

Yes No

If yes, who?

Do you have any of the following documents available?

If yes, please check all documents you currently have available. If you move forward with scheduling an appointment, I will provide instructions for securely uploading any records that are needed once you have created your Client Portal.

Discharge/treatment summary from a prior program or provider Recent laboratory results Recent vital signs Recent EKG Referral/order from a physician or other healthcare provider Other relevant medical records None of the above

If I’m unable to obtain enough information from the documents provided to appropriately assess your needs, are you comfortable signing a separate, specific Release of Information (ROI) so I can request relevant records from your provider?

Yes No Unsure

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