Client Registration and Consent

Appointments:

I agree to make every effort to keep all scheduled appointments. If I cannot attend a scheduled session or must miss a scheduled call, I will use the scheduling system to reschedule, call, or email at least 24 hours before the appointment time. There will be no fee or penalty if the message is sent 24 hours ahead of the scheduled appointment time. I agree to be charged for appointment if no notice is given.

Confidentiality:

I understand that no information about me will be released to anyone unless I provide written authorization. The only exception to this would be if I have not paid for services and are sent to collections for payment; then necessary information will be released in order for payment. I also understand that there are limits to my confidentiality, including the following:

• If I pose a risk of imminent harm to myself or another person, Nutrition Awareness has the legal and/or ethical duty to take the appropriate steps to protect life.
• A court orders to release information
• If there is reason to believe that a child or an elderly person is in danger of or is being abused (physically, emotionally, or sexually), Nutrition Awareness is obligated by law to report the abuse.
• In response to a subpoena from a court of a law or a secretary

Email:

I understand that email may not be a confidential method of communication.

Packages:

If I buy a package of appointments, I understand that after the allotted time frame stated for the package, I am not able to receive a refund for appointments not used.

Counseling Process and Your Rights Regarding Treatment:

I understand that the Nutrition Awareness team and I will work together to define my goals for nutrition counseling. Since nutrition counseling is not an exact science, I understand that the results of counseling can be variable. I understand that the attainment of a positive outcome is dependent upon the effort expended by myself and I am willing to put my part into this experience. I understand that I have the right to ask questions about my counseling. I have a right to choose a dietitian who best suits my needs and purposes. I also have the right to end my counseling at any time.

Consent

I have read through all the above information and have been clearly advised of my rights and responsibilities as a client of Nutrition Awareness, including the HIPAA Notice of Privacy Practices. I understand these rights and responsibilities and agree to abide by them. I consent to counseling, and I understand I have a right to receive a copy of this form upon request.