Questions marked with a * are required
Thank you for your interest in signing up for individualized nutrition counseling services delivered by senior and graduate-level dietetics students in the Department of Human Nutrition, Foods, and Exercise. To get the most out of your experience, please complete the following registration form with as much detail as you feel comfortable providing. 
First and Last Name
VT Email Address
Gender and/or Preferred Pronouns
Briefly describe your primary reason for wanting to meet with a student nutrition counselor (i.e healthy eating on campus, meal planning/cooking/shopping skills, nutrition to support active lifestyle, weight management, vegetarian eating, optimal health/disease prevention, other).

Please note: Virginia Tech student nutrition counselors are not trained to diagnose or treat medical conditions or eating disorders. Please directly consult your primary care physician or Schiffert Health Center if this is a concern.
What other health or medical concerns do you have that your nutrition counselor should know about? This may include food allergies, sensitivities, restrictions or medical history.
List current medications:
Please comment on any other pertinent family medical history:
What, if any, previous experience have you had working with a nutrition counselor or professional to enhance your health?
How ready are you to make changes in your food and nutrition knowledge or choices?
Where do you obtain most of your food or meals?
What foods do you most commonly consume?
Are there any foods you avoid for any reason?
What, if any, cultural or religious influences impact your food choices?
How would you rate your relationship with food? With 1 being "poor, I need help rebuilding my relationship with food" and 10 being "great! I feel comfortable with my relationship with food"
My relationship with food
What is your height? Enter in inches (in) or centimeters (cm).
Optional: What is your weight in pounds (lbs) ?
Movement/Physical Activity: Approximately how many days a week do you engage in moderate to vigorous activity in addition to your normal daily routine (such as brisk walking, jogging, biking, aerobics, or yard work)?
How long are you engaged in physical activity on these days?
Please provide more information about your engagement in physical activity (i.e. type of activity, intensity, factors impacting physical activity, etc.).
How does your stress level or your sleeping habits impact your overall health?
Describe current use of alcohol and/or tobacco products:
Help us get to know you better! What other activities or hobbies do you enjoy?
Is there anything else you would like your nutrition counselor to know before meeting with you?
How did you hear of the service? (check all that apply)
Which of the following best describes your expectations? :
To facilitate scheduling of meetings, please indicate preferred days and times below:
What is your preferred modality for counseling?
I understand that my session may be recorded to assist in a student nutrition counselor's education. Counselors will always give specific notice ahead of recording a session. The recording will only be viewed by the student and instructor, will not include any of my identifying information, and will be disposed of once the review is complete.
Cancellation Policy: The HNFE Nutrition Counseling Service is a high demand service and usually maintains a long wait list. As such, following through with scheduled appointments is a must. Clients are asked to provide 24 hours or more cancellation notice directly to counselors if you are unable to make a meeting as planned. Clients that are a "no show" for a scheduled meeting or have two or more late cancellations are subject to being dropped from the service.
Informed Consent: I understand that the HNFE Nutrition Counseling Service is a training program and that nutrition counseling will be provided by advanced nutrition students under the supervision of a Registered Dietitian Nutritionist. I understand that my relationship with my nutrition counselor is considered confidential and that information will not be released without my written consent. I also understand that the issues that I am working on with my nutrition counselor might be discussed in supervisory sessions with the instructor and other students but will not be attached to my name in any way. I understand that concerns about suicide, homicide, or child abuse may place limitations on confidentiality. In keeping with the university research mission, I understand that data and counseling information may be used for research purposes but that no personal identifying information will be revealed without written consent. I have read the above statements and give my consent to be contacted and receive nutrition counseling services from the Department of Human Nutrition, Foods, and Exercise Nutrition Counseling Service. I understand that I may terminate my involvement at any time by notifying my counselor or the supervising dietitian at eatwell@vt.edu.
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