Informed Consent to Treatment

Effective Date: June 4, 2025

Practice Name: Eat Well Nutrition Counseling, LLC

Provider: Amanda Fredrickson, RD, LD, CD 

Business Address: 917 SW Oak St, Suite 203, Portland, OR 97205

Phone: (503) 567-9945

Email: contact@eatwellnutritioncounseling.com 

The purpose of this document is to inform you, the client, about the nature of nutrition services provided by Amanda Fredrickson, RD, LD, CD and Eat Well Nutrition Counseling, LLC and to obtain your consent to participate in these services.

Nature of Nutrition Services

Nutrition counseling involves the assessment of your dietary habits, health history, and lifestyle to develop personalized nutrition recommendations and support. Services may include:

  • Review of medical and nutrition history

  • Individualized nutrition counseling and education

  • Goal setting and behavior change strategies

  • Meal planning guidance and dietary recommendations

 

Scope of Services

Eat Well Nutrition Counseling, LLC provides the following nutrition services:

  • Preventive nutrition and wellness counseling for all adult lifestages

  • Nutrition fundamentals and education

  • Nutrition for physical activity

  • Medical Nutrition Therapy (MNT) for the following conditions:

    • Pre-diabetes and type 2 diabetes (for individuals not on insulin)

    • High blood pressure (hypertension)

    • High cholesterol (hyperlipidemia)

Please note that services do not include management of complex medical conditions outside the scope listed above (e.g., insulin-dependent diabetes, eating disorders, gastrointestinal disorders, or advanced kidney disease).

It is the client’s responsibility to ensure that the services they are seeking align with the care offered. If you are unsure whether your needs fall within the scope of services provided, you must contact the practice before scheduling your appointment to confirm. If you schedule an appointment for a service that is outside the scope of care and do not cancel at least 48 hours in advance, or attend the appointment for a service not provided, you will be charged the full session fee. 

Geographic Limitations

As a licensed dietitian in Oregon and a certified dietitian in Washington, I provide preventive nutrition counseling and medical nutrition therapy (MNT) only to individuals who reside in Oregon or Washington, in accordance with state licensure laws and professional regulations.

By agreeing to this form, you confirm that you are located in Oregon or Washington at the time of services and agree to notify the practice immediately if this changes. If you move or travel outside of these states, please notify me in advance, as I am unable to continue providing services until you return or establish residency in a state where I am legally authorized to practice.

These geographic limitations are in place to ensure compliance with state laws and to uphold the ethical and legal standards of dietetic practice.

Initial Nutrition Intake Appointment

Your first appointment will be an Initial Nutrition Intake Appointment, which is a foundational session designed to help establish a personalized approach to your nutrition care. During this session, I will gather comprehensive information about your current health and nutrition status, including:

  • Medical history and current health conditions

  • Prescription medications, over-the-counter drugs, and dietary supplements you are taking

  • Dietary habits, food preferences, and eating patterns

  • Lifestyle factors such as physical activity, sleep, and stress

  • Any previous experiences with nutrition counseling or dietary interventions

  • Your personal goals, motivations, and expectations for nutrition therapy


This appointment allows me to understand your unique circumstances and needs so that I can provide recommendations that are safe, effective, and tailored specifically to you. It also helps us determine whether additional medical referrals, lab work, or coordination with your healthcare providers may be appropriate.

Please note that the purpose of the intake is to assess your baseline and gather information necessary for developing an individualized plan of care and that education and general recommendations may not be provided during this session.

Dietary Supplement Recommendations

As part of your nutrition care, I may offer general guidance regarding dietary supplements when appropriate to support your nutritional goals. This may include education on potential benefits, common uses, and how to evaluate supplement quality. However, it is important to understand that:

  • All supplement use should first be discussed with your primary care provider or other appropriate medical professional. Supplements can interact with medications, health conditions, or other factors that I may not be fully aware of or qualified to assess.

  • You are solely responsible for verifying with your healthcare provider that any supplement is safe and appropriate for your individual health needs.

  • While I may provide guidance on how to identify reputable supplement brands and products, I do not endorse specific supplement companies and cannot guarantee the safety, quality, or effectiveness of any product you choose to use.

Any information provided about dietary supplements is for general educational purposes only and should not be interpreted as individualized medical advice. By participating in nutrition counseling, you acknowledge that any decisions you make regarding the use of dietary supplements are made voluntarily and at your own discretion. I am not liable for any adverse effects, interactions, or outcomes related to the use of supplements.

Client Responsibilities

As a client, you are expected to:

  • Provide complete and accurate information about your health and nutrition.

  • Participate actively in setting and working toward goals.

  • Inform your provider of any changes in your medical status or medications.

  • Seek clarification when you do not understand information provided.

 

Registered Dietitian Scope of Practice

  • Nutrition counseling is not a substitute for medical diagnosis or treatment.

  • You should continue to consult with your primary care provider or other health professionals for medical concerns.

  • A Registered Dietitian cannot prescribe or manage medication, or diagnose medical conditions.

If you are taking medications for a health condition (such as high blood pressure, high cholesterol, or blood sugar management), please be aware that improvements through nutrition therapy may affect your medication needs. Only your prescribing provider can assess and adjust your medications appropriately.

It is your responsibility to inform your provider of any changes in symptoms, lab values, or overall health, and to remain under their medical supervision throughout your work with this practice.

Amanda Fredrickson, RD, LD, CD and Eat Well Nutrition Counseling, LLC are not liable for any adverse effects or complications resulting from medications that are not properly monitored or adjusted by your healthcare provider.

 

Confidentiality

Your personal health information will be kept private and confidential in accordance with HIPAA regulations. Information will not be shared without your written consent, except as required by law (e.g., suspected abuse, threats of harm, court orders).

All third-party services used to store or transmit your personal health information comply with HIPAA regulations and Business Associate Agreements (BAAs) are in place, as required by law.

 

Risks and Benefits

Benefits may include:

  • Improved understanding of nutrition and health

  • Healthier eating habits and lifestyle behaviors

  • Improvement in overall health and select health conditions

Possible risks include:

  • Temporary discomfort when changing dietary habits

  • Emotional responses when discussing weight or health history

  • Realization that desired outcomes may take time and effort

 

Voluntary Participation

Participation in nutrition counseling is voluntary, and you may discontinue services at any time. You may also request a copy of this form and discuss any concerns before agreeing.

Personal Belongings and Valuables

Eat Well Nutrition Counseling, LLC is not responsible for your personal belongings and valuables brought into the Eat Well Nutrition Counseling, LLC space. You accept full responsibility and hold Eat Well Nutrition Counseling, LLC harmless for any loss, theft, or damage for personal belongings or valuables retained at the Eat Well Nutrition Counseling, LLC space.

Safe Environment

Weapons or other dangerous objects, illegal drugs, and medications not prescribed by my healthcare provider are not permitted at the Eat Well Nutrition Counseling, LLC premises.

Nondiscrimination

Eat Well Nutrition Counseling, LLC prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

Telehealth (if applicable)

Telehealth is health care provided by any means other than a face-to-face in person visit. In telehealth services, health information is used for consultation, treatment, follow-up, and education. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, a client portal, and remote patient monitoring are all considered telehealth services

I understand:

  • Electronic medical communications carry some level of risk. All attempts are made to operate telehealth in a secure environment, however there are still risks. It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures to prevent this. Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.

  • Despite reasonable efforts on the part of my health care provider, the transmission of medical information could be disrupted or distorted by technical failures.

  • Information exchanged during my telehealth visit will be maintained by Eat Well Nutrition Counseling, LLC. Medical information, including medical records, are governed by the federal and state laws that apply to telehealth.

  • A nutrition evaluation and/or nutrition education via telehealth may limit my provider’s ability to fully address my needs. As a client, I agree to accept responsibility for following my provider’s recommendations, including an in-office visit.

  • I will not record either through audio or video any telehealth session with my provider unless I notify my provider and this is agreed upon. If recording is approved, co-recording will occur.

  • The same fee rates apply for telehealth as for in-person sessions.

  • Portal communication with my provider is meant to be brief, succinct, and pertaining to existing nutrition issues or a recent visit.