Informed Consent and Disclosure
This form outlines my standards of practice as a clinical nutritionist and herbalist. I use my background, experience, and training in my health coaching sessions to provide my clients with the best possible outcome consistent with their health goals.

My goal is to help you achieve the highest state of health and vitality consistent with your own goals. Proper nutrition, herbs and lifestyle choices support the structure and function of the human body. My practice is based on the belief that the human body is innately self-healing, and that the proper use of whole foods, herbs and lifestyle choices may support the body’s return to a healthy state. I do not diagnose or directly treat illness; rather I focus on educating you, the client, on how to best support the body’s innate healing capacity.

All client records are confidential. I hold in strict confidence all information gathered and discussed with you in the office unless you specifically request otherwise. I have a Master of Science degree in Herbal Medicine from the Maryland University of Integrative Health. MUIH is an accredited university, my program was inclusive of over 1,000 hours of supervised clinical experience, in addition to a 90+ graduate credit program. I am board certified as a Certified Nutrition Specialist℠ (CNS), which requires an advanced college degree in the field of nutrition, in addition to over 1,000 clinically supervised hours and a rigorous exam.

You have entered into a health coaching agreement based on the appointment type you have selected. This agreement provides you with the number of sessions and allowed time associated with the appointment type. Appointments may be paid for online when the appointment is scheduled or on the day of the appointment.

This information applies if I recommend an herbal protocol for you. The historical record and modern research indicate that the herbs most often used for healthcare have an exceptional safety record. Herbs should not be used during pregnancy or lactation without expert advice. If you become pregnant you should stop taking herbs immediately until advice is received. It is the responsibility of the client to disclose fully any medications currently in use, including other herbs and supplements so that you can be offered informed advice. Any suggestion that the effect of a drug is being altered by simultaneous use of an herb should be reported directly to all health professionals involved. It is also advisable to stop taking herbs at least 72 hours before a surgical operation, and/or if being prescribed anticoagulants, antiepileptic drugs, and digoxin.

Wisconsin does not license nutritionists or herbalists. Therefore I am disclosing the nature of my practice. The expectations, rights, and responsibilities of the client are respected. I am open to other questions regarding my practice that is not answered above.

I have read this document and I understand the nature and extent of the client and practitioner relationship. I understand that Rebecca does not diagnose or treat disease, or prescribe drugs. I understand that herbal protocols are not a substitute for regular medical care. If I have not already done so, I agree to consult a medical doctor for any serious or life-threatening disease conditions.
  • By selecting "Yes", you are acknowledging and agreeing to the content of this document and signing it electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.
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