Thank you for choosing Mindful Health
We truly are delighted you have chosen our practice.
It is never our intention to bring negativity in to a health and healing environment, we must howevever inform you of the following
Thank you for your understanding.
We look forward to guiding you to a healthier future.
Nature of Services Rendered: The services offered at Mindful heath are counseling in nature and should not in any way be mistaken for medical advice, diagnosis or treatment. Further, supplement, diet and lifestyle recommendations are in no way meant to replace traditional medical care or treatment. Lastly, it is recommended that all participants in Mindful Health’s programs be under the care of a primary care physician.
Not for Medical Purposes: No statements or claims made by Mindful Health, I have been evaluated by the FDA, and no information disseminated by Mindful Health is to be construed as adequate for the purpose of diagnosing, treating or curing disease, nor should it be construed as justification for discontinuing any treatment recommended by a qualified health care professional. In addition, information and/or counseling provided should in no way be considered a substitute for consultation with a licensed health care professional.
Financial Responsibility for all Mindful Health Services: I understand and agree to the following policies regarding financial responsibilities. Payment is required at or before each visit. Services provided at Mindful health are not eligible for reimbursement by my Health Insurance Carrier. I am responsible for all charges incurred for all services rendered or product received from Mindful Health I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for Mindful Health to take action to secure payment of an outstanding balance owed.
No Guarantees: I recognize that Nutritional Counseling is as much an art as a science, and therefore acknowledge that no guarantees have been or can be made regarding the likelihood of success or outcome of any recommendation or suggestion.
Cancellation and/or No-Show Policy: Mindful Health urges you to keep every appointment, as consistency will aid the counseling process thereby allowing you to attain your goals in a shorter time span. We do not always call to confirm appointments. In the event you need to cancel an appointment, we require at least 24 hours notice, excluding Saturday and Sunday. Patients who cancel without proper notice or fail to show for a scheduled appointment will be subject to a full charge for each occurrence. Late arrival may result in a shortened appointment.
Statement of Understanding: Self-help requires intelligence, common sense, and the ability to take responsibility for your own actions. By receiving counseling and/or information from Mindful Health, you agree to hold yourself fully responsible for your own health and wellbeing and to hold harmless Mindful Health, from any litigation for any reason.
Payment/Fee Schedule: If you have any questions regarding fees for our services, please discuss them with us promptly and frankly. In all cases, it is our intent to fully explain and inform you of all procedures, options and fees in advance. If you ever have questions, please do not hesitate to speak any member of our staff.
Payment may be made with any combination of the following: Cash, Checks, MasterCard, Visa, and American Express. For your convenience, we are able to arrange an extended payment plan through the use of a Finance Company. Please feel free to request an application.
Initial Evaluations are typically two hours and cost $275.00 excluding any product you may choose to purchase. Follow-up sessions range from $100.00 - $150.00 based on time and complexity, forty-five minutes being the shortest available session.
Revocation of Authorizations: These authorizations may be revoked by me, in writing, at any time. Such revocation will not affect my financial responsibility to pay for services rendered.
Patient Acknowledgment: I certify that the information I provide is correct. I certify that I am here to receive counseling and for no other purpose. I do not represent any third party.
By signing and dating this form I acknowledge I have discussed, or have had the opportunity to discuss, with my counselor the nature and purpose of nutritional counseling in general and my treatment in particular as well as the contents of these Acknowledgements and Authorizations.
I consent to the counseling offered or recommended to me by my counselor. I intend this consent to apply to all my present and future counseling.
Please sign below to indicate you have read, reviewed and understand the aforementioned