Waiver

Please read each statement below and type your full name stating you acknowledge and agree to each. When complete, please sign your name at the bottom then submit form.

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I understand that the information provided at or in conjunction with the Health Coach services, including dietary recommendations/and or supplemental advice is not intended to be a substitute for professional medical advice, diangnosis or treatment that can be provided by my physician, therapist, licensed dietitian or nutritionist, or any other licensed or registered health care professional.

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I understand that the Health Coach is not a medical or mental health care provider and is NOT providing health care, medical or nutrition therapy services or attempting to diagnose, treat or cure in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. Rather, they are serving only in their capacity as coaches, educators, mentors and guides.

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I agree to seek the advice of my child’s pediatrician, physician or another qualified health care professional prior to and during services regarding any questions or concerns I have about my child’s specific health situation, known or suspected food sensitivities or allergies, dietary restrictions, or any medications I am currently taking. I agree to not disregard professional medical advice or delay seeking professional advice or start/stop taking any medications without speaking to my child’s pediatrician, physician or health care professional.

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I agree to disclose to Health Coach in advance of any known or suspected food allergies or sensitivities, or any other health or mental condition that may be affected during the treatment program. If I suspect that my child is having a medical problem, I agree to inform Health Coach immediately.

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I understand that no claim is made as to the certain efficacy of any nutritional or supplement protocols. I understand that adopting any of these recommendations to implement for my child is voluntary and by choice.

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Any information that is obtained from my medical history, treatment plans, and coaching services will be treated as privileged and confidential and will not be released of revealed to any person other than my healthcare providers without my expressed written consent.

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In the event that my child becomes ill or injured as a result of my participation in Health Coach Services, I hereby release, discharge, and waive any and all liability, damages, causes of action, allegations, suites, sums of money, claims and demands which I have ever had, now have, and could have in the future against Shannon Sciametta and/or Health Coach, arising from my participation in anything related to these services, now or in the future.

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I have carefully read this document and by signing below I consent to all parts of it. I understand that by signing this release, I voluntarily surrender certain legal rights.

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Waiver

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OF EVERYDAY LIFE WITH A NONVERBAL LEARNER.