Client Agreement
In working with Cathy Richards, RD (CDO #3738) at cathyrichardsrd.com, I agree to the following:
● By 12 pm EST on the day prior to my first appointment with Catherine Richards, RD, I will complete all intake questions & paperwork. This includes this Client Agreement, Client Enrollment Form via Acuity, Testimonial Consent Form, Waiver and Acknowledgement and Terms of Service & Privacy Policy.
● I will communicate my progress with my Registered Dietitian (Cathy Richards). I understand that the dietitian is here to help me get better and will do everything within their power to help me improve my health and wellness.
● 24 hours notice is required by cathyrichardsrd.com in order to cancel any appointment. If I do not provide at least 24 hours notice to cancel or reschedule my appointment, I will be deducted 1 session from my program package.
● I agree to purchase a package of services with cathyrichardsrd.com. These packages have been designed to best support my needs. I am fully ready and committed to make the changes needed to my diet and life to improve my health and see results. I understand that the package I purchase is non-refundable* (see guarantee below).
● Each package will expire within 120 days (from purchase)
Satisfaction Guaranteed: cathyrichardsrd.com offers a No Questions Asked, 100% Money Back guarantee. If you are not completely satisfied with the service you receive at the conclusion of your first appointment with our Registered Dietitian (RD) and decided that you don’t want to move forward to work with cathyrichardsrd.com to help you improve your health and wellness, simply let us know at the end of that appointment. You will receive a full refund.
Terms of Service and Privacy Policy
OUR HEALTH PROVIDERS
Cathy Richards, BSc., RD
Registered Dietitian – Energized Health
I received my undergraduate degree at the Brescia College, The University of Western, Ontario and completed additional project management certificate training at Algonquin College. I am a member of the College of Dietitians of Ontario (#3738) and Dietitians of Canada. I have a wide variety of experience in dietetics including, hospital, correctional facilities, long term care centres, department of national defence, primary health care and private practice. I have 3 young children and enjoy spending time with them and my husband. You’ll often find me in the kitchen experimenting with recipes or outdoors with my family.
ETHICAL STANDARDS
As a member in good standing with the College of Dietitians of Ontario (CDO) – I abide by my code of ethics and am accountable to the governing body for ethical and professional standards. You may ask to see these codes at any time. Should you feel that an ethical violation has occurred through which you have experienced some measure of harm, you have a right to register a complaint with the Ethics Committee of the CDO.
RECORDS
Records are kept for each client and kept for a minimum of ten years. Your file contains brief session notes as well as contact information, food and symptom journals, any assessments or information from outside sources, referral notes, emails that are relevant to treatment and any other information obtained during client treatment. This enables us to review sessions as need, helps to keep sessions on track and assists with keeping clients’ goals in focus. Files are kept temporarily on Google Drive during the time that we work together (no more than 6 months) and then are securely transferred to a hard drive that is locked in the offices of cathyrichardsrd.com. The files are then deleted from Google Drive and deleted from any of the provider hard drives. You are welcome to review your file at any time. No records will be shared with any other parties without your signed permission a Consent for Release & Exchange of Information form. It is your choice whether information is released and you are not required to sign any consent if you are not comfortable with it.
CONFIDENTIALITY
Everything that is said in the context of the conversations between service provider and client is kept confidential. There may be times consultations may be made with another health professional. This is similar to a physician getting a “second opinion” and can be very helpful in therapeutic treatment. If consultation does occur, identifying information such as your surname will not be disclosed.
There are few exceptions to confidentiality which you should be aware of:
1. When the client gives written permission (a signed release form) to have information from the counselling sessions communicated to another person.
2. When the client is at risk to hurt themselves or others, as when there is danger of suicide or assault.
3. When there is reason to believe that a child has, is, or may be in danger of sexual or physical abuse or neglect. This includes:
a). When domestic violence is reported and there is a child or children in the home
b). When a client discloses that he/she was abused in childhood and there is a possibility that the abuser may be a danger to other children now. In these situation I am legally bound to report to Family & Children’s Services.
4. When mandated by a court order.
At times it may be suggested that I make contact with other professionals or family members in order to obtain information that will be helpful in your treatment. A signed Consent for Release & Exchange of Information form is required and you have the right to refuse your signature. Should information be requested by anyone outside of my office, you will be notified. If it is not an emergency situation, then signed consent is required and the person/agency requesting the information will not receive it, or be informed you are attending sessions, until the proper signature is received from you. If it is an emergency situation you will be informed via telephone, email or in person, as soon as possible. An emergency situation would be an urgent police, medical or child protection situation. Should there be proceedings before the courts and your records are subpoenaed you will be notified as soon as possible.
YOUR RIGHTS
As a client you have the right:
1. To ask questions at any point in time regarding therapeutic or office procedures.
2. To terminate therapy at any time; you may ask me for a list of possible referral sources.
3. To specify and negotiate therapeutic goals and be an active participant in therapy.
4. To be informed of any information, decisions and actions that will affect you.
5. To be apprised of fees and payment policies.
6. To ask about alternative procedures available for meeting your goals.
7. To review all documentation in your client file.
8. To complain to the Privacy Commissioner of Canada if you are not satisfied with the Privacy Policy in place.
CANCELLATION POLICY
For those appointments that are scheduled but not attended or cancelled with less than 24 hours notice and there was no emergency situation, will be counted as 1 deducted session.
SESSION LENGTH AND FEES
Fees are due in full or in part (depending on the package purchased) upon booking your appointment, prior to your first session with the Registered Dietitian unless otherwise mutually agreed upon and put in writing.
Informed Consent
By signing below, I agree that I have read and understand the above information, and agree to the terms of therapy stated above. My service provider has adequately answered any questions I have at this point in time. I understand I have the right to terminate service at any time, and may ask for a list of referral sources. I understand that it is usually best for Service Providers and clients to make joint decisions about termination of treatment.
By clicking box in acuity I’m indicating that I am giving my consent for Cathy Richards, RD to counsel me and that I understand that I can receive a copy of the above terms by request.
Testimonial Consent Form
I _____________________________________, agree to provide a testimonial of my experience working with my health practitioner at www.cathyrichardsrd.com. The testimonial is a true summary of working with Cathy Richards,RD. I have completed this testimonial using my own thoughts, words and expressions. The signature included with my testimonial (name, age, location, and job title) is completely optional and is information that I am comfortable with associating with my testimonial.
I agree this testimonial may be used on the web, print materials and other media for product or service promotion (i.e. video, soundbite etc.) related to services with cathyrichardsrd.com.
I understand that I may withdraw my testimonial from the use of cathyrichardsrd.com at any time by contacting Cathy Richards directly through email at cathy@cathyrichardsrd.com.
Feedback can be regarding topics that resonate with you, approach to counseling/coaching, advice for others coping with low energy, perspective on our team’s integrative approach, or anything else you wish to share.
My testimonial: submit via email to cathy@cathyrichardsrd.com
Name to be included (can use just first name or be anonymous): please include in your emailed testimonial.
Waiver and Acknowledgement
I, _____________________________________________hereby grant permission for Cathy Richards,RD to correspond with my physician(s) to obtain information relevant to my nutrition treatment and counseling. I acknowledge that any information so obtained by held in strict confidence. I further acknowledge the information provided to me by Cathy Richards is designed to meet my personal dietary needs. It is not suitable for any other individuals and will not be transferred, copied or sold to another person. I understand that the services I have purchased with cathyrichardsrd.com expire within 6 months of my first session.
In order to benefit from the nutrition advice and treatment provided by Cathy Richards, I realize that it is important for me to inform either my physician or Cathy Richards of any changes I make in the application of my diet. It is my responsibility to report any side effects or problems immediately and to make the necessary adjustments to my treatment plan with my physician and/or Cathy Richards. I will not hold my physician or Cathy Richards responsible for any complications that result from my failure to comply with either of the above. I agree to have Cathy Richards on behalf of cathyrichardsrd.com keep my records of our visits and file these in a secure and private place.
I agree to have Cathy Richards contact other health care professionals, as discussed in our visit(s), to benefit in my care and to share my personal information. This may be accomplished by letter, phone, fax or email per PIPEDA.
Cancellation Policy
At least twenty-four hours notice on business days is required to cancel/reschedule your appointment. If less than 24 hours notice is given 1 session will be deducted from your program package. If you are more than 15 minutes late for a scheduled zoom session the appointment will be cancelled and deducted from your program package.
Thank you for your cooperation and understanding.