Feel Great Lose Eight Group Program

Congratulations and Welcome!

You’re about to embark on a fabulous 6-week journey of good nutrition, self-care and lifestyle enhancements that will have you feeling great (and losing some unwanted weight) by the end of it. It’s amazing how the body responds to energizing nutrition, deeper sleep, supportive fasting and a mindset shift.

After reviewing and completing this form, please submit it before our first session. If you have any questions please don’t hesitate to ask - connect@ecohumanhealth.com.

Warmly,

Bree

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CONFIDENTIALITY - The sessions are held in strict confidence.

PROGRAM DURATION - The Feel Great Lose Eight Group Program is a 6-Week program, commencing on the date of our first session and running for 6 consecutive weeks.

WEEKLY SESSIONS - The weekly sessions are a key piece of this program. By signing this, you're committing to showing up for each session.

COMMUNICATION BETWEEN SESSIONS - You are welcome to leave a phone message or send me an email at any time. I will respond at my earliest opportunity.

PAYMENT - The cost of the 6-week Feel Great Lose Eight Program is $397.00. Payment must be paid prior to our first session.

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Please sign here indicating you understand and agree with the above:

Date

Please tell me your story about your health

Please list your 3 primary goals for doing this program, in order of importance

Do you have a medical diagnosis?

YesNo

If yes, please list

Do you currently take any medication? If yes, please list below:

Please list all over-the-counter medications you currently use on a regular basis (aspirin, tylenol, ibuprofen, heartburn/GERD medications, topical cortisone cream, etc.)

Please list all nutritional supplements you currently take (vitamins/minerals, fish oil, amino acids, probiotics, herbs, etc.). Please include brand name and dosage.

Please list any surgeries and hospitalizations (and the year they occurred)?

Do you have a thyroid condition?

Yes - HypothyroidismYes - Autoimmune Thyroid DiseaseI don't know

Have you had your gallbladder removed?

YesNo

Please list any additional symptoms that are bothering you and/or any health conditions you have been diagnosed with, (i.e. Type II Diabetes, Hypothyroidism, PCOS, Crohn’s, etc.)

What have you tried for these problems that have or have not helped? (i.e. supplements, medications, therapies such as chiropractic, etc.

How many meals and snacks do you typically eat each day? Do you feel shaky or sick if you don’t eat on time or you don’t snack?

Describe your current diet (i.e. gluten-free, dairy-free, low-carb, Paleo, organic, vegetarian, vegan, etc.), what foods you commonly eat or exclude, how often you eat out at restaurants, etc.

How often do you have a bowel movement (multiple times a day, once a day, every 2-3 days, once a week)? Do you experience constipation or diarrhea? What consistency is your bowel movement? Do you see any undigested food in your stool? Any mucous, blood, or worm-looking objects in stool?

How much water do you drink daily? What type of water do you drink (tap, bottled, filtered, distilled, well)?

Is there anything else you'd like me to know?

By signing below, you acknowledge that any dietary or supplemental suggestions made by Bree Rudner are entirely educational in nature, and are not intended as the diagnosis, cure or treatment for any disease or ailment. You also acknowledge that your physician is your primary health care provider, and is responsible for supervising all changes in diet and nutrient intake that you make.

Signature

Date

I,

First NameLast Name

, the undersigned, do hereby acknowledge that Bree Rudner states to me that she is an educator and a holistic health counselor and that she is not a licensed medical doctor or licensed primary care provider.

I understand Bree Rudner’s sole intention is to offer me the general educational information I request. If I choose to use this information to work on myself then I affirm that the responsibility is solely mine.

I understand Bree Rudner to state one should never use her information in any way that contradicts, conflicts, or opposes a course of treatment recommended by a primary health provider such as a licensed medical doctor. If I ever perceive or feel that information given by Bree Rudner opposes a licensed doctor’s treatment or recommendations, Bree Rudner strongly advises me to follow the advice and instructions of my licensed primary health care provider.

In consideration of my participation in Functional Diagnostic Nutrition Coaching, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release the above-named individual, its governing board, officers, employees and representatives from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in Functional Diagnostic Nutrition Coaching, whether caused by negligence of the Institution, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the Institution and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described in Functional Diagnostic Nutrition Coaching session.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN NUTRITION AND WELLNESS COUNSELLING AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION.

I, the undersigned, do hereby voluntarily state to understand and acknowledge as accurate all the above comments.

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Thank you!

Please complete the form by clicking on SUBMIT.

Feel Great Lose Eight

General Information

Program Guidelines

Your Story

Other Important Information

Agreement & Release