Forms library

HIPPA Notice of Privacy Practices

Please review before signing the consent form

NourishMentor Policies, Registration, and Consent Form

Please print, complete, and bring to your first visit.

Release of Information Form
If you would like Ruth to communicate with or send progress notes to another person or medical professional,

please print, complete, and bring to your first visit.

Wheel of Nutritional Health

If you would like to complete this self-assessment tool, please print, complete, and bring to your first session.

Coaching Registration  and
Consent Form
If you are a wellness coaching client that is not covered by insurance, please print, complete, and bring to your first visit.
You do not need to complete the other consent form if you are a coaching client.
Instructions for Forms

Please read: HIPPA Notice of Privacy Practices

Please complete: 
* NourishMentor Policies, Registration, and Consent Form
* Release of Information Form (if applicable)

* Wheel of Nutritional Health (if desired)

Thank you for completing forms
before your first visit!

It saves us time in the office, and we can get right to work on your nutritional assessment.  However, if you're having technical difficulties, there are copies of them in the office for you to complete if desired.  

Online clients
 
To meet with Ruth online, click here to sign in to Doxy.me.   At your appointment time, she will meet you there.  Ruth will be able to see that you are in the "waiting room" when you are signed in.

You will also receive an email from NourishMentor with links to forms that you may sign online. If you prefer, you may print the appropriate forms to the right, complete, and fax to 724-289-1891.

Wellness Coaching Clients
(Follow these instructions if Ruth has indicated that you are a coaching client)

Please read: HIPPA Notice of Privacy Practices

Please complete: 
* Coaching Registration and Consent Form
* Release of Information Form (if applicable)

* Wheel of Nutritional Health (if desired)

Forms

Follow-up Form

To help us focus on what is most helpful for you in your next session, please complete this form and either bring it with you to your appointment or email it to me.