Book An Appointment

Appointment Request Form

This comprehensive form is intended to gather as much background information from new clients as possible, so that I may get a better understanding of your nutritional needs prior to your appointment.

Initial Consultations are typically 90-120 minutes,
while Follow Up sessions will range from 30-60 minutes.

Questions? Call (949) 310-5446.

Client Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Date of Birth*
Month
Day
Year
How did you hear about University Nutrition Counseling?
What time of day would you like your appointment?
Please select more than one if you have greater availability.
- Mornings
- Lunch hour
- Afternoons
- Evenings (4-7:30pm)
- Weekends
When would you like to schedule your appointment?
Please indicate if you’d like to be seen immediately, or within the next few weeks.
- Immediately
- Within the next few weeks
- I have a specific date in mind
What day is best for you?
What day is best for you?
MM slash DD slash YYYY
What type of nutrition counseling are you looking for?
- Select All
- General Nutrition & Dietary Counseling
- Health Issue Specific Counseling
- Women’s Health Nutrition
- After 50 Health Nutrition
- Child & Family Nutrition
- Whole Foods/Plant Based Nutrition
- Private Grocery Trips
- Corporate Workshops/Presentations
How can I help you with meeting your nutrition goals?
What fruits do you like the most and the least?
What vegetables do you like the most and the least?
What proteins do you like to eat? And what do you avoid?
Do you like and tolerate dairy products?
Please list any known medical conditions/allergies.
Please list any medication you are currently taking.
Is there anything you’d like me to know before our appointment to ensure a successful and productive start together?
Choose the topics you’d like to discuss with me. A more comprehensive list will help me to prepare and to ensure all of your questions are answered.
Food Topics (Please check all that apply):
- Meal Planning & Meal Prep
- New & easy recipes / Revamped recipes
- Quick & easy meals
- Meal Balancing (When & what to eat)
- Grocery store tour & label reading 101
- Understanding portions
- Managing food & sugar cravings
- Strategies to feel full
- Mindful snacking
- Sports nutrition (Pre/Post Workout Fuel)
- How to eat out while traveling
- Dietary Supplements
- How to increase iron intake
- How to increase calcium intake
- How to increase fruit & vegetable intake
- How to increase fiber intake
- Vegetarian eating / Delicious meat alternatives
- Vegan eating
- Eat healthy for less $
health topics
Health & Wellness (Please check all that apply):
- Lower blood pressure
- Lower cholesterol
- Improve blood sugar / Help to manage diabetes
- Improve & manage inflammation
- Find digestive health relief
- Increase metabolism
- Improve GERD / reflux symptoms
- Improve gout symptoms
- Celiac education & gluten free eating
- Weight Concerns / Finding a healthy weight
- Manage food allergies & intolerances
- Polycystic Ovary Syndrome (PCOS)
- Iron-deficiency (Anemia)
- Manage hormonal imbalances
- Infertility & difficulty conceiving
- Pregnancy & breastfeeding nutrition
- Gestational diabetes
- Pre and post menopause diet
- Osteoporosis relief
- Kidney stone reduction
- Chronic disease prevention
- Bariatric surgery nutritional support
family nutrition
Family Nutrition (Check all that apply):
- Meal Planning & Batch Cooking
- Infant nutrition, baby led weaning, & introducing solids
- Toddler nutrition, increasing food variety & help with picky eating
- Weight concerns (Under & overweight)
- Child food allergies & intolerances
- Healthy meals & snacks
- Teen Nutrition & Wellness
- Healthy eating for kids + teen sports
- Healthy eating for Mom & Dad
lifestyle
Lifestyle Nutrition (Check all that apply):
- Help with binge eating
- Improve my unhealthy relationship with food
- Learn to eat food without guilt
- Break free from unhealthy diet cycles
- Knowledge on how to nourish my body
- Motivational tools and overcoming mental barriers
- How to form health habits that will last a lifetime
Would you like to be added to my newsletter?
Yes, I would like to be added to Tara's newsletter for health tips, special promotions, and more!
Cancellation Policy:*
Your appointment may be cancelled without an additional fee at least 24 hours before your scheduled appointment time. If a cancellation is made within the 24 hour window, you will be charged a standard fee of $50.

A credit card is required to hold your appointment time. Please call the office to provide the information, or wait for a call after the submission of your form. Your appointment will not be confirmed until this information is collected.

You may also reschedule an appointment if necessary, but I ask that you still abide by the same 24 hour rule. Please provide advanced notice for any rescheduled appointments.
I have read and understand the Cancellation Policy
Consent Form & Terms for Nutritional Counseling:*
I am employing the consulting services of University Nutrition Counseling by Tara Tousi, M.S., R.D. so that I can receive information and guidance to enhance my knowledge of health as it relates to the foods I eat and my behaviors associated with eating.

I acknowledge that Tara Tousi, M.S., R.D. is a Registered and Licensed Dietitian/Nutritionist and does not dispense medical advice or diagnose or treat any medical condition.

I am aware that while food and nutrition can be complementary to medical care and an important part of my health and healing, my work with Tara Tousi, M.S., R.D. is not a substitute for diagnosis, treatment, or care by a medical provider.

I am aware that Tara Tousi, M.S., R.D. will keep notes as a record of our work together in order to document the topics we discuss, treatment plans, and other considerations that support me as I learn to nourish my body and optimize my health and wellbeing.

I recognize that any methods of nutritional evaluation or testing provided to me by Tara Tousi, M.S., R.D. are not intended to diagnose disease but instead are intended as guidance and support as I learn new strategies for optimizing my health through nutrition. These assessments are intended to help me monitor my progress in achieving my nutritional goals.

I understand that my medical records and personal information will be kept strictly confidential unless I consent to sharing my medical information or Tara Tousi, M.S., R.D. is compelled to share it by law.

I understand that I am responsible for discussing any dietary changes with my primary care physician. I also acknowledge that I should not discontinue any prescription medications without first consulting my primary care physician.

I realize that it is my responsibility to report any side effects or problems immediately and to make the necessary adjustments to my treatment plan with my physician and/ or Tara Tousi, M.S., R.D. I will not hold Tara Tousi, M.S., R.D. responsible for any complications that result from my failure to comply.

I agree to hold Tara Tousi, M.S., R.D. harmless for claims or damages in connection with our work together. This is a contract between myself and Tara Tousi, M.S., R.D., and I understand that it is also a release of potential liability.

I understand that Tara Tousi, M.S., R.D. has a 24-hour cancellation policy. I am aware that I will be charged an hour’s fee for a missed appointment if proper notice is not given. Proper notice may be given by phone or email.
I have read and agree to the Consent Form & Terms for Nutritional Counseling
Comments
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University Nutrition Counseling by Tara Tousi

Appointment Request Form