Medical Nutrition Therapy Referral
Please fill out to the best of your ability to streamline initiation of MNT services. You may fill out for yourself, or on behalf of the member.
Name of Member
Member Number (if known)
Email (if available)
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Method of Contact
Phone call (with voicemail)
Phone call (without voicemail)
Reason for referral (check all that apply)
Weight loss assistance
Weight gain assistance
Nutritional supplements (i.e. Ensure, Glucerna)
Open Arms applications
Diabetes (Type 1, Type 2, prediabetes, gestational diabetes)
Medical conditions known
Does the member have active Program HH?
HIV Clinic & Physician
Last HIV Appointment
CD4 Labs & Date
Viral Load & Date
Eating Disorder Screening for Primary Care (ESP)
The below questions are included to ensure that the appropriate care model and therapy is provided. The answers to the questionnaire will not diagnose an eating disorder, nor deem the member ineligible for MNT.
Are you satisfied with your eating patterns?
Do you ever eat in secret?
Does your weight affect the way you feel about yourself?
Have any members of your family suffered with an eating disorder?
Do you currently suffer with or have you ever suffered in the past with an eating disorder?
Name & Phone/Email of Referring Person
To expedite care, if consenting to the release of information (below) and recent medical records are available, please fax to (612)822-9668 (HIPAA compliant) to the attention of Emily Ostrow, MS, RDN, LD
I authorize the written, verbal, and/or faxed exchange of information including but not limited to the following records for the purposes of continued care: Emily Ostrow, MS, RD, LD and/or Teal Walters, RD, LD.
I give permission with informed consent to The Aliveness Project and the registered dietitians listed above to exchange the following requested information (please check all that you authorize):
This does NOT include chemical dependency (alcohol/drug use records), mental health records, housing, financial assisistance, or emergency contacts.
Should be Empty: