Nutrition Care Informed Consent

Nutrition Care Informed Consent
Today's Date:*
Date Format: MM slash DD slash YYYY
Client/Patient Name*
First Last
Client/Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Email*
I give consent to Jessica Welch, MS, RDN, LD to provide nutrition care services to myself or to the patient for which I am legally responsible. Nutrition care service will begin with a nutrition assessment, which is the evaluation of your nutritional needs based on appropriate biochemical, anthropometric, physical and dietary data to determine nutrient needs and the recommended appropriate nutritional intake. The nutrition assessment may be followed by nutritional counseling, which includes receiving additional information on appropriate nutritional intake by integrating information from the nutritional assessment along with information on food and other sources of nutrients and meal preparation consistent with my cultural background and socioeconomic status.
Nutrition care services provided by Jessica Welch, MS, RDN, LD, may also include the establishment of priorities, goals and objectives to meet nutritional needs, the provision of nutritional counseling for both normal and therapeutic needs, as well as the development, evaluation, and maintenance of appropriate standards of quality in nutrition care. While nutrition care services can be an important compliment to my health and disease management, I understand these services are not a substitute for medical care.
Methods of nutrition evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessment tests are intended as a guide to developing an appropriate health-supportive program for me, and to monitor my progress in achieving my goals.
Medical records and personal information and history divulged in session to Jessica Welch, MS, RDN, LD will be kept confidential, unless I consent to sharing my medical information by signing a Release of Information. I hereby release and discharge, indemnify, and hold harmless Jessica Welch, MS, RDN, LD, Choices Psychotherapy, their officers, agents, employees, and persons acting on their behalf, from all claims, demands, costs and expenses, and causes of action, either in law or equity arising out of or in any way connected to services I receive from Jessica Welch, MS, RDN, LD.
Agreement*
I have read this consent form and terms contained herein carefully. I understand the terms of this form fully and voluntarily agree to be bound by them.
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p: 952.544.6806

Nutrition Care Informed Consent

Nutrition Care Informed Consent

Choices Psychotherapy

Office: 952-544-6806

Locations

Minnesota Areas Served

Hours

Telemental Health Program Certified

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