The Aliveness Project Medical Nutrition Therapy Referral

*Please Read:

New clients are being accepted and the client you referred will be contacted for scheduling within 5-7 business days. Please email Teal Walters, RDN, LD, CNM at teal@aliveness.org with any questions/concerns. If you are requesting assistance with Open Arms application ONLY, please complete the client portion of the Open Arms application (https://www.openarmsmn.org/hiv-aids-application/) and insert my email (teal@aliveness.org) as the medical provider in all areas. I will receive the Medical Authorization form and contact the client to complete the application within 5-7 business days.

Please note: membership is required for MNT services. If you or your client is not a member of Aliveness.

Name of Member*

First NameLast Name

Pronouns

She/HerHe/HimThey/ThemOther- list pronouns

Member Number (if known)

Email (if available)

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Method of Contact

Phone call (with voicemail)Phone call (without voicemail)EmailText

Reason for referral (check all that apply)*

Weight gain assistance/goalsNutritional supplements (without diabetes)Nutritional supplements (with diabetes: type 1, type 2, prediabetes, gestational diabetes)General or disease/disorder specific nutrition counselingWeight loss assistance/goalsOpen Arms application and medical authorization (if requesting Open Arms medical authorization ONLY, do not submit this form- see note under "Please Read" above)

Nutrition Risk Assessment: Please check all that apply*

Current Height

Current Weight (& estimated date taken)

If recently lost weight without trying, please include the amount lost and timeframe (example: 5 pounds in 2 months)

Medical conditions known

Insurance Type

PrivateMedicareMedicaidOther

Does the member have active Program HH?*

Last HIV Appointment

CD4 Labs & Date

Viral Load & Date

Pharmacy (and city pharmacy is located)*

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*

Medical Nutrition Therapy Referral

Eating Disorder Screening for Primary Care (ESP)

Medical Records

Release of Information