I understand that Katie Goldberg Nutrition and Wellness has a 24-hour cancellation policy for appointments, and I am aware that I will be charged for the full cost of the appointment if proper notice is not given. Should Katie ever have to cancel within 24 hours of the appointment, I understand that I will not be charged, and will receive 20% off my next session.
I understand that Katie Goldberg Nutrition and Wellness does not accept insurance, and that I will be personally responsible for all charges. I am aware that I will be provided a "superbill" that I can submit to my insurance, but that there is no guarantee that any services will be reimbursed. I understand that Katie Goldberg Nutrition and Wellness requires payment prior to service, and that I am required to have a credit card on hand in the case of a missed appointment.
Role of Nutrition Counseling and a Registered Dietitian Nutritionist
I understand that I am employing the counseling services of Katie Goldberg Nutrition and Wellness so that I can obtain information and guidance about health factors within my own control (diet, nutrition, and related behaviors) in order to nourish and support my overall health and wellness. I understand the purpose of nutrition counseling and the benefits and risks, if any, associated with counseling. I understand that results are not guaranteed, whether in a group setting or individual appointments are made.
I understand that Katie Goldberg is a Registered Dietitian Nutritionist and does not dispense medical advice nor prescribe treatment. Rather, she provides education to enhance my knowledge of health as it relates to food, dietary supplements, and behaviors associated with eating. I understand nutrition counseling is not intended for the diagnosis of any disease and is not a substitute for medical diagnosis, treatment, and/or care of a disease by a medical provider.
HIPAA and Privacy
I understand that Katie Goldberg Nutrition and Wellness will keep appointment notes as a record of individual sessions. These notes will document the topics discussed, interventions/plan, goals, and progress. Records will be kept securely. All health history, personal information and medical records shared will be kept strictly confidential unless I have signed an authorization for release or where disclosure is required by law.
I agree to hold Katie Goldberg harmless for claims or damages in connection with our work together. I understand this is is a release of potential liability.