It is a pleasure to welcome you to this Program. Please read the following. If anything is unclear, please ask.

Program Agreement

  • This Agreement is made today between Nourish (The Counselor) and (The Client).
  • It is our goal to help guide you in achieving a healthier lifestyle. The Program you are enrolling in will include discussion of your progress, recommendations and notes. Nourish will provide individualized support and guidance to help you reach the specific goals you set for yourself. You will also receive the Nourish newsletter, invitations for special events, lectures, and other resources like recipes, recordings, foods and other materials. The program provides unlimited e-mail correspondence.
  • The Client understands that the cost of the Program is $150 per hour. The Client may pay the Program Fee per session, in full, or in monthly installments with each month prepaid in advance. Initial here:
  • I understand that Nourish counselors are Certified Health Counselors. They are not physicians trained to diagnose and or treat medical conditions. I give permission to Nourish to communicate with my physician, if necessary, to coordinate nutrition and health advice with my medical history. I agree to keep Nourish informed of any changes in my medical condition. I understand that the success I achieve in this program depends on my ability to make permanent changes in my eating and lifestyle behavior. I am aware that Nourish makes no claims or warranties regarding the results. Initial here:
  • Nourish Policies

    Successful nutrition counseling and self‐care education involves behavioral change. This change requires that I keep my scheduled appointments.
  • “Late” is more than 15 minutes for a program session. If I am late for a session but have at least 30 minutes remaining for the scheduled appointment, the counselor will proceed with the planned session in the time remaining. If I wish to reschedule, I may be charged an additional amount equal to the full cost of the session. Initial here:
  • If I notify the counselor of my need to cancel more than 24 hours prior to the scheduled appointment, every reasonable accommodation will be made to reschedule the session for the same week. If I cancel my scheduled appointment less than 24 hours prior, the session will be rescheduled at the counselor’s earliest convenience. Initial here:
  • If I miss any pre‐paid sessions without prior arrangements, it will be counted as a completed session as this time could have been used for other clients. No refunds or exchanges will be given at any time. If the session missed was not pre‐paid, I will be charged for the session as if it had taken place. Extreme circumstances will be left to Nourish to decide if exceptions to the policy should be made. Initial here:
  • I have been informed that Nourish does not participate with insurance carriers and that: A) It is my responsibility to provide documentation to my insurance provider for possible reimbursement. B) Nourish will provide receipt(s) for any services rendered complete. C) Nourish does not coordinate possible reimbursement on my behalf. Initial here:
  • Nourish maintains confidentiality of all client issues unless she is given permission to communicate with your health care provider, by your signature below, or if she feels your issues present a life-threatening situation. I have read this contract and would like to enter into a counseling agreement with Nourish, and understand my financial responsibilities to Nourish.
  • My virtual signature indicates my understanding and acceptance of the above policy and that I have received a copy of this agreement. Type name here:
  • Date Format: MM slash DD slash YYYY