Sample Nutrition Counseling Referral Form

Building a patient referral network will help generate a steady stream of new clients for your nutrition practice. Share this sample nutrition counseling referral form with physicians and other healthcare professionals who refer clients to your practice. You can include a downloadable link on your website, or strategically reach out to any healthcare professionals in your area. Leverage this referral form to introduce your nutrition practice and build relationships with providers that share the same client-base as you.

As best practices for growing your patient referral network:

  1. After meeting with the referred patient, it’s good practice to follow-up with the referring provider. Consider sending a thank you for the referral (via E-Faxand include a nutrition assessment to be added to your mutual patient’s chart. Even if it wasn’t explicitly requested, sending an assessment will highlight how your services are supporting the patient, and their healthcare team.
  2. For HIPAA-compliance, have your client sign a medical release consent form to allow you to share their private health information
  3. Connect with the referring provider as needed to update them on your mutual client’s progress, or send periodic chart notes to be included in their chart.


Download our sample Nutrition Counseling Referral Form here, but be sure to have legal consult review it, and make adjustments based on your business legal needs.

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