Client Agreement

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Wholistic Lifestyle Nutrition Services  

PLANT-BASED WHOLE-FOOD NUTRITION WHOLISTIC HEALTH INTERVENTION
  ● DISEASE PREVENTION & REVERSAL  LIFESTYLE SCIENCE ASSESSMENT

~ Purify & Protect your Body from harmful toxins and pollutants ~ Encourage Optimum Health & Wellness with WholeFood-PlantBased Nutritional considerations, Enhance Vitality & Longevity, Improve Energy, Detoxify, Rejuvenate, Regenerate; without the need for invasive Surgical procedures, ineffective Pharmaceuticals, OTC Medications or, poisonous Medical treatments  ~

Please Read the following Informed Consent Agreement,  complete the requested information and check the box agreeing to the Terms & Conditions, and click Submit Form.  Your Therapeutic Interview Consultation Package will not be processed until you have completed the following three steps.

1.) Inquiry Application has been received and your initial FREE Consultation has occurred

2.) You have reviewed, discussed and purchased your Nutritional Consultation Package.  

3.)  You have reviewed, agreed to and submitted the Wholistic Lifestyle Nutritional Services - Client Informed Consent Agreement below. A personal eMail, Skype or Telephone Call will provide confirmation when all three steps have been received.  At your earliest convenience, your Wholistic Nutrition Counselor will further arrange subsequent meeting times and additional information . 

     

WHOLISTIC LIFESTYLE NUTRITIONAL SERVICES - CLIENT INFORMED CONSENT AGREEMENT


Thank you for your interest in our nutritional counseling services. This program is designed to provide a mutually beneficial experience for both you the client and ourselves. As a client, you will work one on one with a Wholistic Nutrition Consultant for the amount of sessions purchased. Sessions will last from 1- hour to 1 hour – 30 minutes depending on the specific circumstances surrounding your session package. After submitting this consent form agreement, you will be contacted directly by the counselor to make further arrangements to complete your Therapeutic Questionnaire and further discuss proposed meeting times for the sessions. You will receive a lengthy Therapeutic Questionnaire which will ask you about your health concerns, your eating habits and assess your food behaviors. Please allow a generous amount of time to thoroughly complete the 3-part Therapeutic Questionnaire. Counseling Sessions may be arranged in-person, via Skype or by telephone at the convenience of the client. The first Therapeutic Interview session will be conducted after the Counselor has reviewed and assessed the questionnaire information provided by the client. During the Therapeutic Interview, the counselor will be personally discussing and listening to your specific situation, your goals & objectives, health concerns, food patterns, and lifestyle behaviors based on the answers stated in the Therapeutic Questionnaire. It is in your own best interest to honestly disclose and clarify your answers while completing the Questionnaire so that the Counselor may facilitate and formulate a program tailored to your exact needs. The information disclosed on the Questionnaire and discussed during the Therapeutic Interview is kept in the utmost privacy, and strictly confidential between the Client and Counselors. Absolutely none of the client’s personal information from the questionnaire or counseling sessions will be divulged outside of this privileged and private inter-personal relationship between client and counselors, unless so directed by the Client for purposes of testimonial or research data.

The counseling sessions allow client’s an opportunity to explore and find solutions for nutrition, health status and weight issues. Although Counselors will be following a well-defined clinical guideline, each session will be tailored to your specific needs, expectations, objectives and goals. The overall goal for both counselor and client is to facilitate and enable a health-promoting program to improve the quality of the client’s diet and lifestyle, through sustainable strategies, viable tools, and nutritional education. Counselors utilize a client-centered, motivational and behavior modification approach during sessions with you, based directly on your specific needs. During each session your counselor will work collaboratively with you, to explore your nutrition and weight issues, brainstorm resources and solutions, and help you set achievable goals. Clients will have a variety of tools at your disposal including food models, guidelines, personalized strategies and educational handouts. Homework assignments may be asked of you that will take place as self-guided accountability exercises, and at your discretion in grocery stores, in your neighborhood, or at home in your kitchen and pantry. Client will be held Response-able and will be encouraged and motivated through weekly activity and ‘homework’ assignments, to continue your own Lifestyle path to achieve your nutritional objectives and goals. Counselor will provide additional follow-up after completion of said nutritional program.

At Wholistic Lifestyle Services we suggest nutritional considerations to help prevent and reverse diseases with plant-based whole natural foods and dietary behavior modification. Your Wholistic Nutrition Counselor will take a thorough case history through your personal self-assessment questionnaire and conduct a Therapeutic Interview. It is very important therefore that you fully divulge all pertinent details and inform your Nutritional Consultant immediately of any disease process that you are suffering from and if you are on any prescription medication or over-the-counter drugs. If you are pregnant, suspect you are pregnant or you are breast feeding; please advise your counselor immediately. There may be some nominal side effects and detoxification symptoms associated with dietary and behavior modifications. Extremes are rare, most symptoms and side effects pass quickly but may include, and are not limited to: Possible aggravation of pre-existing symptoms, Allergic reactions to some foods or herbs, Pain, headaches, nausea, dizziness, light-headed, fatigue, constipation, diarrhea, irritability, cravings, frequent urination, frequent bowel movements.

I, the Client will be made aware of my health status assessment based on my own disclosure within the Therapeutic Questionnaire and discussed with me, and facilitated by the Counselor during the Therapeutic Interview process. I have been told by my Nutritional Consultant that there are standard or traditional approaches to treatment, and for personal reasons I am choosing to use alternative nutritional therapies and a nutritionally based cleanse program consisting of juices, foods, and dietary behavior modification therapies to detoxify my body and strengthen my immune system. I have asked Wholistic Nutritional Services to assist me in this process by monitoring my progress and suggesting appropriate nutritional considerations and services. I am aware that these are non-conventional, alternative nutritional considerations and food therapies, and that there may be no proven benefit over more traditional medical modalities, and I have been given no promise of success, cure or remission or other effect of treatment. I am aware of the possibility of beneficial as well as adverse effects. I understand that by making this decision, I have assumed complete and total responsibility for my own health and I release, and hold harmless ENVIRO-HEALTH-TECH, Wholistic Lifestyle Nutritional Services, Dan Miller & Elisabeth Rae and any affiliate or agent from any liability whatsoever arising from the services rendered to me or on my behalf.

As a client of Wholistic Lifestyle Services, I have read the information and understand that my identity will be protected at all times and, if necessary, identifying information will be altered to protect my privacy. I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself in writing or unless law requires it. I understand that I may inquire about my therapeutic questionnaire at anytime and/or retain a copy of it. I understand that information from my therapeutic interview may be analyzed for research purposes and that my identity will be protected and kept confidential. All photographs from the therapeutic program taken before/after are held in strict confidence unless I request them to be published as a testimonial. The information I have provided is complete and inclusive of all health concerns including risk of pregnancy; and all medications, including procedures divulged in the Therapeutic Questionnaire. With this knowledge, I voluntarily consent to nutritional counseling and therapeutic dietary services. I intend this consent form to cover the entire course of the chosen program for my present condition.

I have been informed that these nutritional considerations may not be approved by the FDA and are considered investigational or experimental and that data collected from my participation in these counseling therapies may be used to further the understanding and treatment of disease. This included but not limited to published data, presenting papers in public or private, seminars, lectures and/or journals, or sharing this information with other professionals. I understand data collected from my counseling sessions, if presented, will be kept anonymous and that my confidentiality will be protected at all times. I understand that although the FDA has not approved the use of these nutritional considerations and behavior therapies, the lack of approval does not render the use of these alternative therapies such as ozone, hydrogen peroxide, and plant-based whole foods unlawful. In North America, these therapies are considered investigational or experimental. I have read and understand the handouts, fliers, documents and webpages, on the nutritional considerations and lifestyle behavior modifications provided by Wholistic Lifestyle Services and have been informed about the specific processes involved with the therapeutic nutritional counseling and dietary considerations. I desire to undergo this nutritional consultation program after having considered the information contained in the information provided to me through my conversations with the Nutritional Consultant and through materials provided to me by their offices to educate me about the program and services.

I understand that there have been no warranties, assurances, or guarantees of success made to me as to result or cure, and I will not hold the Nutritional Consultant/Counselor responsible for my individual result(s) of the treatment(s) that I have requested. I fully understand that there may be other alternative and/or standard treatments available for my condition. I acknowledge that I have had the opportunity to ask any questions of my physician or healthcare practitioner, with respect to the proposed therapy and the behavior modification strategies to be utilized. All of my questions have been answered to my full satisfaction. My signature on this agreement will constitute a full and final release of any legal responsibility resulting from my case, and / or any other medical treatment that may be necessary as a result thereof.
I understand that I am free to withdraw my consent and to discontinue participation in these services at any time, with full knowledge of the associated cancellation fees. Partial Refunds are given on a pro rata basis and at the discretion of Wholistic Lifestyle Services. I also confirm that I have the ability to accept or reject these services and counseling sessions of my own free will and choice. I accept full responsibility for any additional fees or cancellation fees, incurred during the nutritional counseling program and services. Full payment for all charges is required before start of program and therapeutic interview. In special circumstances, any additional arrangements may be made and will be presented in writing to reflect any changes to the purchased program. We accept payment by PayPal, credit card or personal eChecks. I understand that once I have started my Guided Nutritional program there are only partial refunds minus any fees for materials, shipping & handling and administrative processes. I understand that my treatment program must be completed within the designated timeframe and at the outset, within six (6) months from the date of purchase. I also understand that my program is not transferable.

I understand that the Nutritional Consultant will rely on statements made by me to determine that the tailored and personalized program is safe and effective for me. WE STRONGLY SUGGEST THAT IN ADDITION TO OUR NUTRITIONAL CONSULTATION SERVICES, YOU MAINTAIN A RELATIONSHIP WITH ONE OR MORE PHYSICIAN OR HEALTHCARE PRACTITIONERS QUALIFIED TO DIAGNOSE HEALTH CONDITION(S), MONITORING DIAGNOSTICS OR REVIEW MEDICATIONS AND UPDATES. I have informed Wholistic Lifestyle Services of all my known physical conditions, medical conditions, and medications. I assume all responsibility and liability for any condition(s) I have failed to disclose. I choose to do this of my own free will.
 

Please provide the following client contact information:        (*required fields) 

First Name *
Last Name *
Phone w/ area code *
Optional Phone
E-mail *
Skype Contact Profile *
Referred by
Mailing Address *
Address (cont.)
City *
State/Province *
Zip/Postal Code *
Country

Enter additional Home or Billing address if desired: 

Alternate Address
Address (cont.)
City
State/Province
Zip/Postal Code

**You must check the following boxes and complete the date of informed consent to accept the above noted Wholistic Lifestyle Services - Client Informed Consent, Terms & Conditions Agreement.  Terms & Conditions must be accepted, and the Client Consent Form & Consultation Package submitted prior to any Nutrition Counseling Session Partial refunds are available on a pro-rated basis minus any applied cancellation fees.**

Yes*, I (enter name), , have read and fully understand the above informed consent statement and agree to meet with the Wholistic Lifestyle Services Nutritional Consultant at the forthcoming pre-arranged agreed times, or inform them via email or telephone with a 24 hour re-scheduling notice; and, I agree to complete and to be held accountable for my chosen therapeutic nutritional program within a maximum six (6) months of the acceptance date noted below in order to fully receive all the benefits available to me with the program chosen.

I have read and agree to the above Informed Consent Agreement Terms and Conditions. Checking these boxes and completing this form constitutes an agreement to the terms and conditions and authorizes Enviro-Health-Tech, Wholistic LifeStyle Services to process my payment and process my Client Agreement for Nutritional Consulting. Checking this box and completing this Agreement form is considered an authorized signatory of the Client Informed Consent Terms & Conditions Agreement.

  Date of Application Acceptance  * (today's date)

Yes*, I have purchased my Nutritional Counseling Package

**Client Informed Consent will not be accepted without checking the box agreeing to the Terms & Conditions, purchasing your package and entering the date of this order.**

Enter special instructions, requests, ask questions or submit additional details

Yes, I would like to be contacted to further discuss and/or confirm this application before final approval.  

                              Contact by Phone             Contact by Email        Contact by Skype

Click once below on Submit Form for your Client Informed Consent and Nutritional Consulting Package to be immediately processed.  Reaching the Form Confirmation  page ensures that the information has been properly submitted. If you do not reach the confirmation page, reset form and try back later.

 

ENVIRO-HEALTH-TECH

Wholistic Lifestyle Nutrition Consultation Services

Dan Miller - Elisabeth Rae
4825 Highway 95, Suite #2-230
Fort Mohave Arizona 86426


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Office: 928-758-7689 

MobileOffice: 360-220-2518

Voicemail: 1-800-906-2624

Skype --->  live:envirohealthtech

EMAIL: envirohealthtech@frontier.com

 


 

 

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