Self Pay Application Form

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Complete this quick form to get started!

Thank you for your interest in working with us! We use this application to capture a general idea of your current baseline with nutrition and what you're looking to improve.

After we receive your information, we'll send you pricing information and a link to book a free discovery call with a provider.

We look forward to chatting with you soon!

Full Name

State

If you could be any form of cooked potato, which would you be and why?

Is there a specific provider you're looking to work with? [select all that apply]

Would you prefer in-person (New Orleans, Louisiana) or virtual nutrition coaching?

In-person (New Orleans, Louisiana)

Virtual

On a scale of 1 to 4, how would you rate your relationship with food at the moment?

1 - Food feels like the enemy

2 - Struggling with food decisions and lacking confidence

3 - Feeling neutral and ready to find more grounding and stability

4 - I feel at peace with food most of the time

What are your current concerns or struggles with nutrition?

On a scale of 1 to 4, how would you describe your relationship with movement?

1 - Movement feels like a punishment or a chore.

2 - I like movement, but it often feels all-or-nothing to me.

3 - I enjoy movement and want to find ways to be more consistent without getting obsessed.

4 - I'm feeling confident and consistent with my movement routine.

Picture yourself 6 months from now. How are you feeling about food and movement? What habits do you have in place?

Is there anything else you'd like us to know?

You can expect to hear back via email within 7 business days.

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