INFORMED CONSENT FORM & TERMS FOR NUTRITIONAL COUNSELING
I am employing the counseling services of Cara Axelrod MS, RD, LDN / Your Dietitian For Life LLC so that I can obtain information and guidance about health factors within my own control (diet, nutrition, and related food behaviors) in order to nourish and support my health and wellness.
I understand that Cara Axelrod is a Registered Dietitian/Nutritionist, and does not dispense medical advice nor prescribe treatment. Rather, she provides education to enhance my knowledge of health as it relates to foods, dietary supplements, my relationship with food and behaviors associated with eating.
While nutritional and botanical support can be an important compliment to my medical care, I understand nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical or psychological provider.
Nutritional evaluation or testing provided in counseling is not intended for the diagnoses of disease. Rather, these assessment tests are intended as a guide to developing an appropriate health-supportive program for me, and to monitor
my progress in achieving my goals.
I understand that Your Dietitian For Life LLC will keep therapy notes as a record of our work together. These notes document the topics that we talk about, interventions used, and treatment plan or any other considerations that may be helpful to your work with me. I understand that Your Dietitian For Life LLC has the right to refuse any request for amendment of therapy documentation.
I acknowledge that I have read and understand the HIPAA privacy notice provided by Your Dietitian For Life LLC in virtual or hard copy form.
I understand that Your Dietitian For Life LLC offers a HIPAA-compliant telehealth communication method. If I choose to forgo this method and utilize a means of communication or physical location more convenient for me, Your Dietitian For Life LLC is not liable for any potential breach of privacy or any applicable HIPAA rights.
I agree to hold Your Dietitian For Life LLC harmless for claims or damages in connection with our work together. This is a contract between myself and Your Dietitian For Life LLC, and I understand that it is also a release of potential liability.
I understand that Your Dietitian For Life LLC has a 24-hour cancellation policy.
Fees and Payment: You agree to the designated fee at the time of purchase. Cash, Zelle, and major credit cards are accepted. I understand that Your Dietitian For Life LLC does not take insurance nor does she assist with any efforts a client may take on their own to submit claims to their insurance. A payment is due before the first session, and is non-refundable.
Extras: If you have questions between sessions, you are welcome to email me. I will do my best to answer as soon as possible. But, please note that I maintain a full-time schedule.
Nutrition counseling services may be terminated at the discretion of Your Dietitian For Life LLC if written notification is provided to a client 30 days in advance of final appointment. This will include a listing of referrals for continuity of care.
If any provision in this agreement is found unenforceable, then that provision will be severed from this agreement and not affect the validity and enforceability of any remaining provision.