Consultation Form

Rebecca Meyerson, MS
Certified Nutrition Counselor
Simply Healthy Living
rebecca.meyerson@gmail.com

As your Certified Nutrition Counselor (CNC), we can discover the food and lifestyle choices that support your changes to a happy, healthy life. Throughout this program we will:
- Set and accomplish health goals
- Explore new foods
- Understand and reduce cravings
- Increase energy
- Improve personal relationships

This agreement is made today between Rebecca Meyerson and (Client). The program in which you are about to enroll will include all of the following an initial one hour consultation, followed by bimonthly follow up visits to discuss progress and suggestions, a variety of handouts, recipes, as well as recommendations of Standard Process products. I understand that my clients have busy schedules and I take pride in not keeping them waiting or keeping them longer than planned. Each session will end on time, so please be on time. (Client) understands that the initial visit is $125 for an hour, and $100 for forty-five minute biweekly visits. Rebecca Meyerson encourages the client to continue to visit and be treated by his/her healthcare professionals including, without limitation, a physician. The client understands that Rebecca is not acting in the capacity of a doctor, and is not providing health care, medical services, and will not diagnose, treat or cure in any manner whatsoever any disease of the human body.

(Client) has chosen to work with the counselor and understand that the information received should not be seen as medical or nursing advice and is not meant to that the place of your seeing licensed health professionals. (Client) acknowledged that the client takes full responsibility for the client’s life and well being, as well as the lives and well being of the client’s family and children (where applicable), and all decisions made during and after this program.

The client acknowledges the counselor will keep all information exchanged during the program sessions in strict confidentiality. Additionally, the client is aware that the client prohibits the counselor from disclosing protected healthcare information, except upon written authorization. In terms of this agreement and acceptable, please sign the acceptance below. By doing so, the client acknowledges that he/she has received a copy of this letter agreement, he/she has had an opportunity to discuss the contents with the counselor and if desired, to have it reviewed by an attorney and the client understands, accepts and agrees to abide by the terms hereof.

Financial Policy Payment is due as services are rendered. You may pay by cash or personal check (with proper identification). In order to avoid misunderstandings, please let me know immediately if there terms are not satisfactory. All returned checks will incur a charge of $25.

Cancellation Policy I understand that any appointment (either in person or a phone appointment) cancelled or rescheduled by the client is subject to a 24 hour notice of cancellation. I agree to pay for consultations missed (either in person or a phone appointment) when I do not give a 24 hour cancellation notice.

CLIENT HEALTH INFORMATION


For any over the counter drugs and supplements please fill out the following. How many times a day do you use the following?