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Please complete this new client intake form if you will be using my coaching services.  Please note, that if your program does not include coaching calls, coaching calls are available as per the below fee schedule:

Fee Schedule

Initial Consult (60 minutes) -- $180

Follow Up (45 minutes) -- $120


Note that these rates are for coaching calls that are in addition to what's included in the services we've discussed.

 

In an effort to reduce my impact on the environment, and save you some time, I have made my entire new client intake package available online.  You must complete all of these forms prior to your first meeting with me.  The first few pages are about my privacy policies, to which you just read and agree.  You are always welcome to contact me if you have further questions about my policies.

This form can take about 15 minutes to fill out, depending on specific details.

Public Statement

My Privacy Commitment to You: I am committed to protecting your privacy and ensuring the confidentiality of your personal health information. The types of personal health information I collect may include your name, address, phone number, email address, date of birth, health history, family health history, health measurements, health services provided to or received by you, and identity of your health care providers.

I collect, use and disclose personal health information for the following purposes: (1) to provide nutritional consulting to our clients; (2) to conduct quality improvement and risk management activities; (3) to obtain payment for services provided (from you or others); (4) to advise clients about special events or opportunities (but I will always obtain express consent to do so). I will collect, use and disclose only as much personal health information as is needed to achieve these purposes. You can withhold or withdraw your consent to the collection, use or disclosure of your personal health information by contacting me directly (details below).

Access to Health Records: You have the right to seek access to your health records that I keep and to ask me to correct a record if you believe it is inaccurate or incomplete. Please contact me for more information.

Questions or Concerns?

If you have questions or want to make a complaint about our privacy practices, please contact: Jennifer Jodouin. You also have the right to complain to the Information and Privacy Commissioner of Ontario at the address below if you have concerns about my privacy practices or how your personal health information has been handled:

Information and Privacy Commissioner/Ontario

2 Bloor Street East, Suite 1400,

Toronto, Ontario M4W 1A8

Telephone: Toronto Area (416/local 905): (416) 326-3333

Long Distance: 1 (800) 387-0073 (within Ontario)

TDD/TTY: (416) 325-7539

FAX: (416) 325-9195

www.ipc.on.ca



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