Please note that this form must be signed prior to your first appointment.
Wellness Consultation Informed Consent Form
Our goal is to help you achieve the highest state of wellness consistent with your own goals.
Rebecca Harder will perform a comprehensive wellness assessment to determine wellness needs; plan and implement a lifestyle and food based intervention; and monitor and evaluate your progress.
This consultation may identify specific wellness needs or provide needed education about personalized detoxification programs, whole food, plant based food and supplement suggestions, lifestyle modifications, optimal weight programs, suggestions about exercise and coaching about changes supporting greater health and function. Recommendations may include nutritional supplement such as food based probiotics, herbs, amino acids and fatty acids.
I understand that Rebecca Harder (Gastra Girl) does not function as a medical physician, a licensed nutritionist, psychologist, counselor or other licensed practitioner. If I have not already done so, I agree to consult a medical doctor for any serious or life-threatening disease conditions, either for myself or someone under my guardianship.
I understand that no suggestions are being made for me to discontinue any treatment being provided by any other health care professional. It is important that I maintain regular visits with my primary care physician and medical specialists as appropriate, to ensure proper medical care.
Rebecca Harder is not a medical doctor or other licensed health care professional. Consultations are not a substitute for medical care and do not include diagnosing or treating disease. Educational consultations in lifestyle can serve as an excellent adjunct to a medical doctor’s treatment and are intended to expand a client’s consideration of available options and are intended to assist with compliance with any medical care a client may be receiving as well as assist in the use of natural means to support health.
No aspect of a consultation should be understood as a basis to avoid any diagnostic work-up or discontinue any medical treatment. Clients should follow-up with their physician to discuss any modifications they intend to make to their health protocols, to evaluate any testing results or to change protocols as necessary.
In appropriate cases, Rebecca Harder may make suggestions for herbal or nutritional supplements. These interventions are provided to support wellness or help with symptoms such as headaches or digestive distress that have been evaluated by a physician. Some of the nutritional, herbal and other methods suggested by Rebecca Harder are considered to be complementary, alternative, or holistic care, and may not be accepted by the larger community of medical physicians.
Rebecca Harder provides non-medical whole foods plan consultation and suggestions, which can include education about nutrition, personalized whole foods and dietary recommendations, meal plans, lifestyle modifications, optimal weight programs, advice about exercise and coaching about lifestyle changes supporting greater health and function. Suggestions may include herbal and nutritional supplement such as vitamins, minerals, herbs, amino acids and fatty acids. Rebecca Harder is not a licensed dietician or nutritionist.
Wellness coaching supports clients who wish to cultivate positive and healthy lifestyles. The coaching relationship assists clients to understand their needs, develop wellness goals identified by the client or by their physician or other licensed professional. The coach provides education about health options the client can explore with their physician, other health professional or on their own as appropriate. Coaching encourages self-health management to assist clients to formulate their health goals and devise and follow strategies to implement lifestyle and behavior changes. Coaching and educating about healthy choices and available resources is tailored to a client’s particular needs so that they may make informed choices about their health options. Choices are driven by the client’s perception of their needs and any health goals. Coaching offers support; questions regarding the diagnosis or treatment of any health or nutritional condition should be directed to the client’s physician, nutritionist or other health care professional.
Clients may wish to explore dietary supplements on their own, which can be a valuable support for health. While herbs and botanical products are generally available over-the-counter and are considered safe based upon their long history of use, many of them have not been widely tested. The historical record and modern research indicate that herbs and supplements most often used to support health have a good safety record. Similarly, confirmed cases of herb, nutrient and drug interactions are rare though risks are not entirely understood. Herb, nutrient and drug interactions can occur.
Rebecca Harder is a National Board Certified Colon Hydrotherapist and I-ACT Certified Insructor. She has given over 20,000 colon hydrotherapy sessions and has specialized in detoxification and digestive care since 2003.
Regarding interactions between plant based foods and supplements and pharmeceutical medications research is still emerging and there may be unknown interactions. Adverse events can occur after using any active substance, including an allergic response. Negative reactions to natural remedies may include rare allergic reactions, including headaches, itching, hives, difficulty breathing, and very rarely, even shock or death. While unlikely, clients choosing to take products could have an adverse reaction or experience a reduction or increase in the effect of medications. This can have serious consequences for some medications, such as for the control of high blood pressure, blood sugar or control of bleeding/clotting. Clients should let their physician know what herbs or other dietary supplements they are taking, particularly prior to surgery or other procedures. Clients should discuss any concerns with Michelle Gamble and the primary physician as appropriate about any adverse effects or reactions.
To reduce risk it is imperative that you disclose to your coach:
1) all medications, supplements and herbs currently in use,
2) any liver or kidney disease (past or present),
3) any allergies,
4) if you plan to become pregnant or are currently pregnant or breastfeeding.
It is important to stay within the recommended dosage. Any side effects or suspected supplement/drug interactions should be reported directly to all health professionals involved. It is also advisable to stop taking herbs and supplements seven (7) days before and after a surgical operation, and/or in the event of being prescribed a new medication.
Before beginning any exercise program, clients with medical conditions or who have not exercised in some time should obtain medical clearance before beginning any exercise program. Exercise programs always contain some risk of injury or trauma if done incorrectly, in excess, or because of underlying medical conditions.
Notice to Pregnant Women: All female clients must alert Rebecca Harder (Gastra Girl) if they are pregnant or breastfeeding or suspect they could become pregnant to enhance the safety of any lifestyle changes, nutritional and herbal product recommendations and to allow any appropriate referrals can be considered.
No Guarantees: Like any effort to improve health, consulting is an art as well as a science. No guarantees are made that a client will gain any benefit or not suffer any adverse consequences.
Like many interventions, some nutritional and natural remedies may not have not been subjected to rigorous scientific study and there are wide individual differences in responses to these services. The responsibility for improvement lies with the client; consultations are merely a catalyst for change.
Important Insurance Notice: Rebecca Harder's services are not covered by health care services and are not reimbursed by insurance, Medicare or any other third-party payor. Payment in full (currently waived for internship nutrition hours) is required at each visit. Clients agree not to submit claims for these services, are responsible for payment even if an effort is made to obtain reimbursement that is denied, whether because services are “non-covered” or “not medically necessary.”
Office Policies: At least a 24-hour cancellation is required to remove the reserved session time. If a client repeatedly cancels in less than 24 hours or is a "no show" to sessions, the waived session opportunity will be cancelled for this client.
Informed Consent for Minors
I certify that I am the parent or legal guardian of the child/ward and that I have lawful custody for the purposes of authorizing health care consultations and for the release of protected health information. To the best of my knowledge, there is parental agreement about undergoing this consultation. In the event I am or become separated or divorced or any circumstances arise under which a parental disagreement over this authorization becomes an issue, I will hold Rebecca Harder (Gastra Girl) harmless.
I hereby authorize consultation or coaching in wellness and lifestyle activities from Rebecca Harder (Gastra Girl). I understand and agree to the financial and other terms set forth above. I understand the nature of this consultation, including the risks of possible adverse reactions. I have been adequately informed, and my questions have been satisfactorily answered. I am solely responsible for the decision to see Rebecca Harder (Gastra Girl). I represent that I am seeking assessment and consultation to further my own health and for no other reason. I do not represent a third party and sign this voluntarily.