Thank you for completing your new client form! Please review the following policies below and digitally sign to proceed.
Effective Date: October 2019
I am scheduling counseling services with Powered by Plants, LLC for information and guidance about nutrition, lifestyle and related behaviors to support my personal health goals.
I understand that Brittany Summerlin, Owner of Powered by Plants, LLC, or any employees of Powered by Plants, LLC, is a Registered Dietitian and does not diagnose medical conditions nor prescribe any treatments. Instead, I will be provided with information and resources to enhance my knowledge of health as it relates to nutrition including dietary supplements (i.e. vitamins), and behavioral/lifestyle modifications.
Nutritional evaluation and assessment provided in counseling is not intended for the diagnoses of disease. These assessments may serve as a guide to appropriate programs for me, or to monitor progress with health goals that I determine with guidance from counseling.
I agree to hold Powered by Plants, LLC and Brittany Verras or her contract RDs, harmless for claims or damages in connection with our work together. This is a release of potential liability.
I understand and agree to a cancellation policy such that I must give notice 4 hours in advance of any cancellation or I will be liable to pay a $50 fee within 24 hours of cancelling. If I do not provide notice, I will pay the full amount of our session price.
A credit card will be required to hold an appointment time. The client's card will be charged $1.00 but the full amount will not be charged until the appointment time (minus the $1.00). Payment is expected immediately following the session or can be done prior if the client wishes. Payments can be provided by the card on file, cash, accepted credit or debit cards via Square Payments, or digital forms including Venmo, Zelle or Paypal. Client will complete set up of any digital payment options prior to our initial session.
Failure to pay within 24 hours of the session is considered breach of service agreement. For every day past due, a $25 fee will be added, and, following 30 days of nonpayment, the owed amount will be forwarded to a third party collection agency.
If you have any questions about this notice, please contact me at email@example.com or by phone 678-575-5089.