DISCLOSURE & CONSENT
By joining this program, I acknowledge and agree that I understand the following, with respect to services rendered by Deanna Larson MD LLC and their employees, consultants, and technical assistants, including Deanna Larson (“Coach”).
While Coach is licensed in Nebraska and Iowa as a Medical Doctor, I am choosing to engage Deanna Larson as a life coach and/or weight coach only. This involves an individual assessment; goal setting; empowering thought, feeling, and action identification to achieve my goals; and individual, group and/or retreat coaching.
Benefits, Alternatives & Risks: Benefits of life coaching include: greater relaxation, ease and feeling of overall well-being. Benefits can also include, but are not limited to, increased profitability, efficiency, and overall satisfaction with my profession and business. Benefits of weight coaching include: movement toward weight loss and overall improved state of health and well-being. Alternatives to both include self-help techniques and medical or psychological care. Risks of both include distress, mental health issues which require referral to a suitable, licensed healthcare provider, dissatisfaction with results, and over-relying on life and/or weight coaching notwithstanding recommendations by life coach, when I know I should see a licensed physician, mental healthcare or other professional, to treat a physical or psychological condition. Additional risks can include a decrease in profitability, efficiency, and possible dissatisfaction with my profession and business.
No Medical or Psychological Services: I am not engaging Coach for any medical or psychological or other healthcare services. I understand that Coach in her services pursuant to this Disclosure and Consent, does not diagnose, treat, or claim to cure any medical or psychological or other condition, and that Coach’s services are not designed to replace conventional treatment methods of medical or psychological conditions. Coach does not handle medical emergencies of any kind. 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. I agree to seek medical assistance or psychotherapy or any other appropriate physical or mental diagnosis and treatment from a duly licensed practitioner (such as a licensed medical doctor or licensed psychologist) if I find that these distressing aspects create a danger for myself or for others.
The state of Nebraska 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.
Not Replacing Current Medical Care. Coach is acting in a supportive consultative coaching capacity and not as a primary care physician. Accordingly, Coach is not replacing care currently provided to me by other physicians or licensed healthcare providers, such as my current primary care physician, internist, gynecologist, cardiologist, gastroenterologist, psychiatrist, psychologist, pediatrician (in the case of children) or other specialty care. Coach has advised me that I should maintain a relationship with a physician who is available to provide emergent and urgent care. If I encounter a medical emergency and am not able to obtain care from my primary care physician, I will contact 911 or report to a hospital emergency department. Coach does not provide on-call services.
Not Replacing Current Financial Services Coach is acting in a supportive consultative coaching capacity and not as a financial advisor, certified public accountant, or legal advisor. Accordingly, Coach is not replacing services currently provided to me by certified public accountants, financial advisors, and licensed legal counsel. Coach has advised me that I should maintain a relationship with my certified public accountant, tax advisor, financial advisor, and legal counsel. I will notify my current financial service providers and legal counsel of any changes I choose to make as a result of advice received from Coach.
No Claims or Guarantees: I understand that Coach makes no representations, claims or guarantees that my medical problems or conditions will be cured, solved, or helped by Coach’s recommendations. I understand that Coach makes no representations, claims or guarantees that my business or current employment status will be benefited or helped by Coach’s recommendations. I understand and acknowledge that Coach has made no implications, warranties, promises, suggestions, projections, representations, or guarantees whatsoever to me about future prospects or earnings, or that I will earn any money, with respect to following Coach’s advice. Any earnings or income statements, or any earnings or income examples, are only estimates of what I could possibly earn but are not guarantees that I will earn the same or similar income. I am advised to do my own due diligence when it comes to making business decisions and I should use caution and seek the advice of qualified professionals. I should check with my accountant, lawyer, or professional advisor, before acting on any information.
Referrals: I understand that Coach may recommend that I seek other types of treatment from other health professionals who are not affiliated with Coach. I understand that Coach may recommend that I seek other types of advice from other financial professionals who are not affiliated with Coach. I understand that Coach does not supervise these professionals and is not responsible for them. I understand that they are not her employees and that they will bill separately for their services.
Assumption of Risk; Indemnity: 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 Coach 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 treatments or services described above, or arising out of or in connection with referral to other practitioners, merchants, or financial professionals for delivery of any services. As a result, I agree not to pursue a claim against any of the foregoing, if I am dissatisfied with the results of the above services.
Video-Coaching: Video coaching involves the use of audio-visual or other electronic communications to interact with you with respect to the services herein. The benefit is speed of communication and access without physical travel; risks include inadequate communication due to the lack of physical presence. Additionally, in rare circumstances, security protocols could fail causing a breach of privacy. The alternative is an in-person face to face visit.
Group-Sessions: Coach provides the option and opportunity to participate in group sessions. These sessions are beneficial because they use a group session format that allows participants to discuss their own journeys and allow others to benefit from hearing from others and hearing coaching advice given to those participants. I UNDERSTAND AND CONSENT TO ALL OF COACH’S GROUP SESSIONS BEING RECORDED AND POSTED TO COACH’S PORTAL. If I do not want to be recorded then I acknowledge and understand I may choose to either not participate in the group sessions, or I may attend a group session by listening only and choosing to turn my audio and video off, and I may choose to submit questions anonymously. Coach will post all recordings to the client portal and will attempt to keep most, if not all, recordings password protected, however, Coach will not guarantee or warrant that all recordings will be password protected.
Private Health Information & HIPAA Compliance: I understand and acknowledge that as a physician I have an obligation under state and/or federal law, including HIPAA, to use appropriate safeguards to ensure patient information and medical information is protected from unauthorized use or disclosure. I understand that it is my duty and obligation to only refer to de-identified patient data when discussing particulars of a situation in my sessions or group-sessions of health coaching.
Arbitration: Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in Omaha, Nebraska, before one (1) arbitrator. The arbitration shall be administered by Kelly Gering, Shared Story Mediation. 1603 Farnam Street, Omaha NE Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. Each party has read and understood this Section (Arbitration) and understands that it thereby agrees to submit any claims arising out of this Agreement to binding arbitration, and that this dispute resolution provision constitutes a waiver of the Party’s right to a jury trial. HOWEVER, prior to either party initiating Arbitration of any dispute, the parties agree to attempt mediation of the dispute with a mutually agreeable trained mediator in or near Omaha, Nebraska. “Trained mediator” means a professional with actual training and experience in the field of Mediation and/or dispute resolution. EACH PARTY HAS READ AND UNDERSTANDS THIS SECTION and UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, THE PARTY AGREES TO SUBMIT ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH, OR TERMINATION THEREOF TO MEDIATION AND ARBITRATION, AND THAT THE DISPUTE RESOLUTION PROVISIONS SET FORTH IN THIS SECTION CONSTITUTE A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL.
NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I have carefully read this form and acknowledge that I understand it. I have had opportunities to ask questions, and accept and agree to all of the terms above. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.
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