Neuronutrition Associates

Menu
Patient Portal
Patient Portal

New Patient Application

Step 1: Patient Information

(If filling out for a child, please use the child’s name and DOB)

Patient Full Name(Required)
MM slash DD slash YYYY
Parent/Guardian Name (if applicable)

 

 

Step 2: Location & Licensure

Due to medical licensing laws, our providers can only serve patients in specific states. Please let us know where you reside so we can match you with the appropriate provider.

Where do you currently reside?(Required)

Jana Roso, APRN, PNP — Texas only

Caroline Dixon, APRN. FNP — Texas only

Alexis Maple, CNC — All 50 states (nutrition consultation only, focused on preconception, pregnancy, and postpartum)

 

 

Step 3: Preferred Provider

We will do our best to honor your provider preference.

Please note that Dr. Emily Gutierrez has very limited availability.

 

 

Step 4: Your Health Goals

What draws you to this model of care?

 

 

Step 5: Testing Preferences

We utilize comprehensive testing to help guide care, including specialty labs for hormones, gut health, metabolic markers, toxicants, and genomics. Functional lab kits are typically paid out-of-pocket; conventional labs may be billed to insurance.

How interested are you in doing comprehensive lab testing?(Required)
(0 = not interested, 5 = very interested)

 

 

Step 6: Virtual and In-Person Visit Options

Neuronutrition Associates offers both virtual and in-person appointments.

Are you open to receiving care via:(Required)
(Select all that apply)

 

 

Step 7: Financial Commitment & Provider Options

Our care begins with initiation packages that include multiple provider and coaching visits, designed to build a strong foundation for your wellness journey. Packages are valid for 12 months and must be paid in full before scheduling.

Jana Roso, APRN, PNP-C, FMAPS

Available in TX only

Pediatric only (20 and under)

  • Initiation Package $1,800: Includes 3 provider visits + 2 health coaching sessions
  • Follow-up Visits: $500 (60 minutes), $450 (45 minutes)
  • Visit Duration: Minimum 45 minutes

Caroline Dixon, APRN, FNP-C

Available in TX only

  • Initiation Package$1,500: Includes 3 provider visits + 2 health coaching sessions
  • Follow-up Visits: $400 (60 minutes), $350 (45 minutes)
  • Visit Duration: Minimum 45 minutes

Alexis Maple, FMCHC, CNC

All 50 states (health coaching and nutrition consultation only, focused on preconception, pregnancy, and postpartum)

Alexis Maple, Certified Health Coach, Certified Nutrition Consultant.

Available in all 50 states

  • Health Coaching, Nutrition Consultation: $150 (45 minutes)
  • Visit Format: Telemedicine or in-office (Austin, TX)
  • Specialization: Preconception, pregnancy, postpartum nutrition and health coaching
  • Alexis offers nutrition support tailored to each stage of the reproductive journey.
Are you financially prepared to move forward with one of the initiation packages or nutrition consultations listed above?(Required)

 

 

Step 8: Readiness to Begin

Are you ready to take the next step in your health journey?(Required)

 

 

Step 9: Additional Information

Optional

 

 

Step 10: Newsletter Subscription

Would you like to receive occasional updates, educational content, and resources from Neuronutrition Associates?(Required)

 

 

Final Step

Thank you for completing the Neuronutrition Associates screening form.

If your application is approved, you will receive instructions to register as a new patient and submit payment for your selected provider's initiation package or nutrition consultation. Once registered, you will receive a welcome email with a video outlining the next steps in your care.

If you do not receive an email from us shortly, please check your spam or junk folder.

For questions, contact: info@neuronutritionassociates.com