By signing this agreement, I, the client whose signature appears below (“Client”), acknowledge and agree to the following with respect to services by Teresa Collier and her employees or independent contractors, agents, and affiliates (collectively, “Provider”).
1. Required disclosures. Provider is not a licensed physician. The services offered by Provider are alternative or complementary to healing arts services licensed by Nevada. The services that Provider offers are not licensed by Nevada.
A. Nature of Services. Provider provides the following services: lifestyle assessment to review habits and goals with regard to overall well-being, including personal care, fitness, and nutrition.
B. Theory of Treatment. The theory of treatment upon which the services are based is that good self-care enhances overall wellness.
C. Provider’s Training and Experience. Provider has certifications in physical fitness, holistic health coaching and does extensive research regarding healthy choices.
2. Contact/Touch: I specifically authorize Provider to use physical contact and touch, and I consent to the same as necessary for the delivery of services described above. I will let Provider know anytime I am uncomfortable.
3. No Guarantee: I recognize that Provider cannot guarantee results or any specific outcomes from our work together, and that Provider offers no warranties of any kind. I am solely responsible for any action taken based on my interpretation of any information presented.
4. Right to Discontinue Services; No Additional Individuals Permitted. I understand that Provider has the right to refuse to continue delivering services at any time for any reason whatsoever. Also, I understand that unless this is a group session, no minors or additional individuals are permitted.
5. No Medical, Psychological, or Massage Therapy Services. I am not engaging Provider for any medical services, psychological services, or massage therapy or bodywork services. I understand that Provider does not diagnose, treat, or claim to cure any medical or psychological condition, and that Provider’s services are not designed to replace conventional treatment methods of medical or psychological conditions. I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as licensed physicians and psychologists.
6. My Responsibility For My Self-Care. I understand that working with Provider may bring up distressing feelings, images, thoughts and behaviors. Specifically, temporary emotional releases may occur in the form of sadness, anxiety, fear or stress. Such feelings are often brief and self-resolving; however, emotional support when these feelings arise is recommended. Some of these distressing experiences may persist or resurface at a later time. I agree to seek medical assistance or psychotherapy or any other appropriate physical or mental diagnosis and treatment from a practitioner duly licensed in my state (such as a licensed medical doctor or licensed psychologist) and/or my respective state if I find that these distressing aspects create a danger to me or to others.
7. Drugs and Alcohol. Any medication prescribed by my medical doctor should be taken as instructed by my doctor. However, certain drugs and alcohol can interfere with the services, and I will disclose their use to Provider so that Provider can ascertain whether to continue providing me with services. If I show up for a session inebriated than my deposit will be forfeited and Provider will not provide me with any services.
8. Assumption of Risk; Indemnity. I knowingly, voluntarily, and intelligently decide to receive the services described above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Provider and her managers, members, employees, agents, staff, volunteers, assigns and agents from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described above, or arising out of or in connection with referral to other practitioners or merchants for delivery of any services. As a result, I agree not to pursue a claim against any of the foregoing, if I am dissatisfied with the results of the above services. I UNDERSTAND THAT THIS IS A WAIVER & RELEASE OF LIABILITY TO WHICH I AM BOUND AND UNDER WHICH I AM WAIVING IMPORTANT LEGAL RIGHTS. This indemnity, waiver and release is intended to be as broad as is allowed under applicable law and applies to any and all claims for damages, regardless of whether they are alleged caused by Provider.
9. Nutritional Advice: State law allows any person to provide nutritional advice or give advice concerning proper nutrition–which is the giving of advice as to the role of food and food ingredients, including dietary supplements. This state law does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than one who is a licensed health practitioner to state that any product might cure any disease, disorder, or condition.
10. Cancellation Policy: I understand there is a 24-hour appointment cancellation policy and that if I miss my scheduled appointment or cancel within less than 24-hour notice, I am responsible for cost of the scheduled session as indicated under fees and charges below. Cancellation may done by text, voicemail or email.
11. No Refunds: Provider does not offer any refund for office visits or services of any kind, with the exception of a well-documented family emergency. Provider maintains good boundaries regarding scheduled appointments, and does not make up for time if I am late.
12. No Participation in Insurance Plans; No Responsibility for Determining Benefits: Provider does not participate in any insurance panels, and do not accept assignment from any insurance company. Consequently, I am responsible for payment in full at time of service and charges are determined by Provider. Further, Provider is not responsible for determining eligibility for benefits or for assisting me with collecting insurance benefits and have no responsibility to correspond with or telephone or email any insurer.
13. Telepractice: I understand that Provider may work with me via telephone, text, email, or online, and I agree to the same.
14. Agreement to Arbitrate. I agree that any dispute or claim arising out of my receipt of services described by this Disclosure, including as to whether any treatment services were unnecessary or unauthorized, or were improperly, negligently, or incompletely rendered, will be determined by arbitration, before one (1) arbitrator. The arbitration shall be administered by JAMS pursuant to its Consumer Arbitration Rules. Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I have carefully read this form and acknowledge that I understand it. I also acknowledge that I have been provided with a copy of this form. No representations or statements, oral or written, have been made to me, apart from those described in this form. This form will be interpreted under Nevada law, and Nevada will be the forum for any claims filed under or incident to this form. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.