Outreach Nutrition Consultation Services Application

Name of Institution/ Dormitory/ School/ Organization

Please fill in the following information

* Compulsory

Name of Institution/ Dormitory/ School/ Organization *

Address *

Flat

Floor

Block

Building Name

Estate/Village Name

Street Name and Number

Area

Service Users of Residential Dormitory Institutions

No. of People *

Age Group *

Does the center have/have a nutritionist to provide nutrition services? *

Currently YesNoOnce there, the last service period is

Service Period *

to *

No. of Visits *

One-time PlanPeriodic Plan:

Visit Once

Time *

Interested Services

Nutrition screening for service users

Approximate number of people screened

Individual nutrition assessment, diet therapy and counseling

Budget per time

Approximate number of interviews

Menu review, meal portion evaluation, meal improvement and standardization

Review the menu

Once

Value-added training for nutrition topic staff/chefs

Number of times held

Once

Approximate number of participants

Proposed theme

Nutrition talks and nutrition support group

Number of times held

Once

Approximate number of participants

Proposed theme

Recipe nutrition analysis consultancy service

Provide recipes

Qty

Budget Amount of the Above Services

HKD

Services

Name of Institution/ Dormitory/ School/ Organization

Contact Person

Service Users of Residential Dormitory Institutions

Interested Services

Other Available Information (If Applicable)