The Aliveness Project Medical Nutrition Therapy Referral

Name of Member*

First NameLast Name

Pronouns

She/herHe/HimThey/them

Please note: membership is required for MNT services. If you or your client is not a member of Aliveness, the membership form below must be completed and submitted in addition to this form.

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 assistanceNutritional supplements (without diabetes)Nutritional supplements (with diabetes: type 1, type 2, prediabetes, gestational diabetes)Open Arms Medical Provider Authorization*

*Please complete the eligibility portion of the Open Arms application (below) and list Emily Ostrow as the medical provider for authorization. This must be completed prior to submitting this referral form.

https://www.openarmsmn.org/hiv-aids-application/

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

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