COACHING CLIENT AGREEMENT AND DISCLOSURE STATEMENT
Jenna Blake, MSN, APRN
As a board-certified nurse practitioner, I am licensed to order tests, diagnose medical conditions, prescribe medications, and manage medical conditions only the in states that I am licensed in. The services I perform, whether in person, via email, by phone, or by video conferencing, are at all times restricted to providing general coaching services. I am prohibited from providing a conventional medical disease diagnosis, treating a medical condition, ordering diagnostic testing, recommending the discontinuation of treatment prescribed or recommended by another medical provider, or to refer you to a specific medical provider. If I am licensed in the state you reside in, then a mutual decision can be made to utilize my license to the fullest to provide you medical care afforded to me by my license, but unless otherwise agreed upon, I am not seeing you as a patient utilizing my nurse practitioner license and board certification. I am providing you coaching services only. The nature of health/wellness/life coaching are as followed:
Health and wellness coaching: As a health/wellness/life coach, I am here to support you in obtaining optimal health and wellness by guiding you in the right direction to make positive change in your life. I can provide recommendations to various diagnostic testing and treatment options, but I cannot order any specific medical intervention that is required by state licensure. If I recommend any specific testing, you will need to obtain this by a licensed medical professional under their direction. My job is to explore the lifestyle changes you want, facilitate a process of change and to help you develop the tools you need to achieve your health and wellness goals. The coaching services we provide are designed to help you reach an optimal state of well-being through mutual decision making, not through the diagnosis or treatment of a medical condition.
Potential Benefits: Health and wellness coaching can help you lose weight, eat better, and to bring your body into a state of balance and well being through the mutually agreed upon interventions and recommendations.
Potential Risks: Anytime a person makes changes to their life, potential issues can arise as your body goes through the initial shock of change. You are fully responsible for your health and wellbeing during and after any coaching session including the choices and decisions you make towards your goals. Remember, coaching is not a replacement for medical care administered by a licensed medical professional. At all times you agree to continue routine care with your primary care provider and/or specialist and will only use the information provided to you in the coaching sessions for informational purposes only.
No Guarantees: There are no guarantees to coaching and your success ultimately depends on the amount of effort you make towards achieving optimal health and wellness.
Alternatives to coaching: You are voluntarily seeking our coaching services on your own accord. Alternatives to coaching would be to do nothing at all, seek to make the positive changes in your life through self study, or to seek out the help from a licensed medical provider in your state.
COACHING CLIENT AGREEMENT AND DISCLOSURE STATEMENT
Recommendations: As a coaching client, you will always discuss any recommendations provided to you by Jenna Blake/Her Rooted Wellness with your primary care provider, mental health provider, or licensed medical specialist before implementing them into your life.
Informed Consent: By checking the box on the checkout page, you are voluntarily consenting to our coaching services and acknowledge receipt of this form:
- I have read or had read to me this entire form and have had the chance to ask questions and they were answered to my satisfaction. I understand the nature and limitations of health coaching to be provided and voluntary agree to receiving coaching.
- I understand that Jenna Blake/Her Rooted Wellness is not a licensed in my state and that I am not seeing a medical diagnosis, testing, or specific medical treatment that would require the counsel of a licensed medical provider in my state.
- I understand the risks, benefits and alternatives to the coaching services provided. I understand that I am not being given a guarantee or being promised a specific result or outcome.
- I understand that health/wellness/life coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, etc. I acknowledge that deciding how to handle the issues in my life and to implement the recommendations provided to me are solely my responsibility.
- I understand health/wellness/life coaching is a relationship built on trust with my coach and that is designed to facilitate the development and achievement of personal, professional, and/or business goals
- I understand that I am fully responsible for the decisions I make for my health and wellbeing during and after my coaching session. I understand that if I am not comfortable or if I am having ill effects from the coaching sessions, that I will notify my coach immediately or seek out the care of a medical provider in my state.
- I understand and agree that lab testing results, lab recommendations, or any other medical recommendation discussed during a coaching session are not attempting to diagnose, treat, or cure, in any manner whatsoever,
any disease, condition or other physical or mental ailment of the human body. Rather, I understand and agree
that any lab testing results or specific recommendations that are shared with me are for purely educational and information purposes only. - I understand it is my responsibility to maintain a relationship with a licensed medical provider in my state. I understand that health/wellness coaching is not meant to replace the care from my licensed medical provider.
- I understand that health/wellness/life coaching is not meant to diagnose or treat any specific medical conditions. I understand that if I am seeking out a specific medical diagnosis or treatment, that I will follow up and seek advice from my licensed medical provider in my state of residence.
- I understand that wellness coaching is not to be used as a replacement for professional advice. I will seek professional guidance for legal, medical, financial, business, or educational issues arising in my life. I understand that all decisions in these areas are exclusively mine, and I acknowledge that my decisions and actions are my responsibility.
I voluntarily consent to obtaining health/wellness/life coaching through Jenna Blake/Her Rooted Wellness and that I hold Jenna Blake/Her Rooted Wellness harmless from any and all liability, damages, causes of
action, allegations, suits, sums of money, claims and demands whatsoever, in lay or equity, which the Client ever
had, now has or will have in the future against Jenna Blake/Her Rooted Wellness arising from the Client’s past or future
participation in, or otherwise with respect to, the coaching sessions, even if arising from the gross negligence of the
Jenna Blake/ Her Rooted Wellness
REFUND POLICY
The Estima Circle Group Program is for people who are committed to implementing real changes in their life. We do not provide refunds for any of our products/training/programs/digital products/events. Our information is proven to work for those who implement it and if you do not intend to implement, we cannot be responsible for the lack of results you will get.
If you have no intention of implementing, please do not purchase any of our programs, courses, digital products or event tickets.
CONTACT INFORMATION
Questions about the Terms of Service should be sent to us at jenna@herrootedwellness.com
