Real Food Reset Nutrition Coaching Registration Form Logo
  • Form

  • Welcome to Real Food Reset Nutrition Coaching

    Mission Statement: At Real Food Reset, we believe nutrition is more than macros and menus—it's a ritual of self-respect, reflection, and transformation. We offer ethical coaching rooted in care, guiding individuals toward sustainable habits and nourishment that fuels real, lasting change.
  • Before you begin:

    The information provided with this program is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any medical condition. We do not prescribe therapeutic diets or offer medical advice. Always consult with your physician or qualified healthcare provider before beginning any nutrition, lifestyle, or wellness program. By engaging with our content, coaching, or resources, you acknowledge and accept full responsibility for your personal health decisions and outcomes.
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  • Consent to Participate in Coaching Services

    I understand that the coaching services provided are designed to support personal wellness, nutrition education, mindset development, and lifestyle goals. These services are not a substitute for medical care, mental health treatment, or therapeutic intervention. I acknowledge that the coach does not diagnose medical conditions, prescribe therapeutic diets, or offer clinical advice.I voluntarily consent to participate in coaching sessions and related services, and I understand that my participation is based on mutual respect, collaboration, and personal responsibility. I agree to communicate openly about my goals, needs, and boundaries, and I understand that I may withdraw from coaching at any time.By signing below, I affirm that I have read and understood this consent form, and I accept full responsibility for my choices, actions, and outcomes related to coaching participation.
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  • Confidentiality Notice (HIPAA-Compliant)

    All personal health information shared during coaching sessions, intake processes, and through digital platforms is protected under the Health Insurance Portability and Accountability Act (HIPAA). This includes any information related to your physical or mental health, health history, goals, progress notes, and communications.We are committed to maintaining the privacy and security of your Protected Health Information (PHI). Your information will only be used to support your coaching experience and will not be disclosed to third parties without your written consent, except as required by law (e.g., risk of harm, mandated reporting, or legal subpoena).We use secure, HIPAA-compliant platforms to store and manage client data. While we take reasonable precautions to protect your information, no system is entirely immune to breaches. You are encouraged to use discretion when sharing sensitive details online.By engaging in coaching services, you acknowledge and accept these privacy practices and understand your rights under HIPAA, including the right to access your records, request corrections, and withdraw consent at any time.
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  • Notice of Privacy Practices

    This notice describes how information shared during coaching services may be used and disclosed, and how you can access your personal information.Your Privacy Matters We are committed to protecting your privacy. All personal information shared through coaching sessions, intake forms, client portals, and related communications is treated with respect and confidentiality. This includes health history, goals, progress notes, and any materials you upload or share.Use of Information Your information may be used to:Support your coaching experience and track progressCommunicate with you regarding services, scheduling, and resourcesMaintain records for internal documentation and service qualityWe do not sell, share, or disclose your information to third parties without your consent, except when required by law (e.g., court order, risk of harm, or mandated reporting).Digital Platforms We use secure platforms (e.g., Carepatron, Zoho Mail) to manage client data. While we take reasonable steps to protect your information, no system is 100% immune to breaches. Please use discretion when sharing sensitive details online.Your Rights You have the right to:Request access to your recordsAsk for corrections to inaccurate informationWithdraw consent or discontinue services at any timeQuestions or Concerns If you have questions about this notice or how your information is handled, please reach out directly. We’re here to ensure your experience feels safe, transparent, and respectful.
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  • Demographics

    Your responses help me understand your lived experience and tailor our coaching journey with compassion and relevance. These questions are optional, and your privacy is respected.
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  • Defining Your Goals

    Understanding your goals helps us create a coaching plan that aligns with your vision and priorities.
  • What are your top 3 goals?

  • Nutrition Snapshot

  • Should be Empty: