The Aliveness Project ONS Interest Form

Medical Nutrition Therapy Interest Form

Oral Nutrition Therapy and Nutrition Education/Counseling
Due to limited state and federal funding, Aliveness Medical Nutrition Therapy (MNT) has limited capacity to accept new nutrition patients.

Instead of new referrals, we are now accepting interest forms from/for people who:
1. Are an Aliveness member.
  - To sign up please visit https://aliveness.org/membership-application/.
2. Have active Ryan White/Program HH.
  - To sign up/renew please visit https://edocs.mn.gov/forms/DHS-3539-ENG.
3. Have interest in oral nutrition therapy ("ONS" such as Ensure, Boost, Glucerna) covered by the DHS Enteral Nutrition Therapy Program.
If you or the patient meets all three criterion above, please complete the forms on the next two pages.

If you have questions or concerns, please contact Teal Walters, Clinical Nutrition Manager and Licensed, Registered Dietitian Nutritionist at Aliveness. Phone: 612-367-6257 | Email: teal@aliveness.org

Information of Person Completing Form

If you are filling this form out for yourself, please provide your own information again and state "self" as in the "relationship to member" field.
Form Completer's Name

First NameLast Name
Form Completer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Form Completer's Email
example@example.com
Form Completer's Relationship to Member
Signature of Form Completer or Member
Today's Date

MonthDayYear
Date
Should be Empty:

Medical Nutrition Therapy Interest Form