Nutrition Consent

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Nutrition Consent

Nutrition, Health & Wellness Coaching Consent Form

Email *

I understand that the Nutrition, Health & Wellness coach does not dispense medical advice nor prescribe treatment. Rather, he/she provides education to enhance my knowledge of health as it relates to foods, dietary supplements, and behaviors associated with eating. While nutritional support can be an important complement to my medical care, I understand nutrition, health & wellness coaching is not a substitute for diagnosis, treatment, or care of disease by a medical provider. *

I understand the above.

Required

If the Client is under the care of a healthcare professional or currently uses prescription medications, the Client should discuss any dietary changes or potential dietary supplement use with his or her primary care physician, and should not discontinue any prescription medications without first consulting his or her primary care physician. *

I understand the above.

Required

The Client acknowledges that the care that they receive during their nutrition, health & wellness coaching sessions is separate from the care that they receive from any medical facility in that the coaching session are in no way intended to be construed as medical advice or care. The client should continue regular medical supervision and care by their primary care physician. *

I understand the above.

Required

Personal Responsibility and Release of Health Care Related Claims

The Client acknowledges that the Client takes full responsibility for the Client’s life and well-being, as well as the lives and well-being of the Client’s family and children (where applicable), and all decisions made during and after the duration of the client’s nutrition, health & wellness coaching sessions. *

I understand the above.

Required

The Client expressly assumes the risks of nutrition, health & wellness coaching sessions, including the risks of trying new foods, and the risks inherent in making lifestyle changes. *

I understand the above.

The Client releases the nutrition, health & wellness coach and the Center for Therapy & Counseling Services from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in lay or equity, which the Client ever had, now has or will have in the future against the nutrition, health & wellness coach, arising from the Client’s past or future participation in, or otherwise with respect to, the coaching sessions, unless arising from the gross negligence of the coach. *

I understand the above.

Confidentiality

The nutrition, health & wellness coach will keep the Client’s information private, and will not share the Client’s information to any third party unless compelled to do so by law or with the consent of the Client. *

I understand the above.

Payments and Refunds

Payments are due at the time of service and there are no refunds for payments made to the Center for Therapy & Counseling Services. *

I understand the above.

No-Show/Cancellation Policy

In the event that the Client does not show up to an appointment or cancels less than 24 hours in advance of a scheduled appointment the coach and/or the Center for Therapy & Counseling Services, reserves the right to charge the client a $50 cancellation fee. *

I understand the above.

By typing my full name below, I show I understand and agree with the above. *

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