Alkymis, Inc.

Consent & Disclosure (under California B&P Code §2053.6)

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By signing this form below, I understand and acknowledge all of the following:

 

  1. Required disclosures. Shanna Lee and Shanna Lee, Inc. (individually and collectively, “Provider”) are not licensed physicians or psychologists or providers of medical or psychological services. The services offered by Provider are alternative or complementary to healing arts services licensed by California.  The services that Provider offers are not licensed by California.  The nature of the services Provider will offer are as follows: Nutrition Coaching, Empowerment Coaching, Life Coaching

 

Where appropriate, Provider may also recommend consumer health products that are commonly available in retail stores or online, but these recommendations in no way involve prescription or treatment; any decisions regarding medical care should be made in consultation with my physician.

 

The theory upon which the services are based is as follows:  To provide coaching and guidance in self-empowerment.

 

Provider’s education, training, experience, and other qualifications are as follows:  Bachelor of Science in Interpersonal Communication, Certified Transformational Nutrition Coach, Certified Touchstone For Life Coach, Certified Transformational Coach, 

 

Provider’s services involve only education and information.  If I choose to use this information to work on myself then I take full responsibility for the same.

 

  1. Contact/touch: Although I understand that Provider’s services generally do not involve physical contact, I specifically authorize Provider to use physical contact and touch and consent to the same as necessary for the delivery of the services for adults described above.  

 

  1. No Guarantee: I recognize that Provider cannot guarantee results or any specific outcomes from our work together.  I am solely responsible for any action taken based on my interpretation of any information presented. 

 

  1. Right to Discontinue Services; No Refunds. I understand that Provider has the right to refuse to continue delivering services at any time for any reason whatsoever and will refund the client’s payment in full for the portion of unused services.  Beyond that, Provider does not offer any refund for office visits or services of any kind.  Provider maintains good boundaries regarding scheduled appointments, and does not make up for time if I am late.

 

  1. No Medical, Psychological, or Massage Therapy services.  I am not engaging Provider for any medical or psychological or massage therapy services.  I understand that Provider does not diagnose, treat, or claim to cure any medical or psychological condition, and that Provider’s services are not designed to replace conventional treatment methods of medical or psychological conditions.  I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as physicians and psychologists.

 

  1. My Responsibility for My Self-Care.  I understand that any inner-directed work or reflection can bring up distressing feelings, images, thoughts and behaviors. I agree to seek medical assistance or psychotherapy or any other appropriate physical or mental diagnosis and treatment from a practitioner duly licensed in California (such as a licensed medical doctor or licensed psychologist) if I find that these distressing aspects create a danger for myself or for others.

 

  1. No Mental Illness.  I acknowledge that I have not been hospitalized for any psychiatric condition within the last ten (10) years, nor have charges been brought against me based on my behavior.

 

  1. Assumption of Risk.  I knowingly, voluntarily, and intelligently decide to receive the services described above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Provider and her agents from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described above, or arising out of or in connection with referral to other practitioners or merchants for delivery of any services. This indemnity, waiver and release is intended to be as broad as is allowed under applicable law and applies to any and all claims for damages, regardless of whether they are alleged caused by Provider.

 

  1. Cancellation.  I understand there is a 24-hour appointment cancellation policy and that if I miss my scheduled appointment or cancel within less than 24-hour notice, I am responsible for half the cost of the session.

 

  1. Financial Responsibility. I understand that Provider does not accept insurance or negotiate with insurers, and that Provider’s services are likely not reimbursed by any insurer.  I am financially responsible for my session and agree to pay the charges incurred. Provider does not accept partial payment or waive payment.

 

  1. Intellectual Property.  Any work product of any type created by Provider during or in connection with any services Provider renders to me, belongs solely to Provider.  Other than being provided with a copy for my own use, I will have no rights in such work product whatsoever. This means, for example, that I will not disseminate, reproduce, or publish any such work or any derivative thereof in any form whatsoever, without Provider’s express written consent.

 

  1. Nutritional Advice: State law allows any person to provide nutritional advice or give advice concerning proper nutrition—which is the giving of advice as to the role of food and food ingredients, including dietary supplements. This state law does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than one who is a licensed health practitioner to state that any product might cure any disease, disorder, or condition.

 

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