Sankofa Preliminary Adult Metabolic Assessment Form - Informed Consent, and Privacy Policy

Sankofa Preliminary Adult Metabolic Assessment Form - Informed Consent, and Privacy Policy

Functional Health Intake form Create a HIPAA Compliant Sankofa Preliminary Adult Metabolic Assessment Form - Informed Consent, and Privacy Policy today. Form Preview
  • Preliminary Adult Metabolic Assessment Form - Informed Consent, and Privacy Policy

    Welcome to Sankofa Healing and Enrichment, Inc.!
  • Please Note:

    These forms will take approximately 30 minutes to complete.

    Consent and policy forms within the intake will require your E-Signature.

    Please do not print these forms. Please fill them out online prior to your preliminary integrative wellness consultation. Dr. Michelle Gamble, DN (Sankofa Healing and Enrichment, Inc.) follows a paperless practice utilzing secure electronic health records.

    All information is confidential.

    Dr. Michelle Gamble, DN

    Non-Medical Doctor of Naturology

    Integrative Wellness Specialist

  • Informed Consent

  • Please note that this form must be signed prior to your first appointment.

    General Wellness Consultation Informed Consent Form

    Our goal is to help you achieve the highest state of health consistent with your own goals.

    Michelle Gamble will perform a comprehensive nutrition assessment to determine nutritional needs; plan and implement a nutrition intervention; and monitor and evaluate your progress.

    This consultation may identify specific health needs or provide needed education about nutrition, personalized whole foods and dietary recommendations, meal plans, lifestyle modifications, weight loss or detoxification programs, advice about exercise and coaching about lifestyle changes supporting greater health and function. Recommendations may include herbal and nutritional supplement such as vitamins, minerals, herbs, amino acids and fatty acids.

    I understand that Michelle Gamble/Sankofa Healing and Enrichment, Inc. does not function as a medical physician, a licensed nutritionist, psychologist, counselor or other licensed practitioner. If I have not already done so, I agree to consult a medical doctor for any serious or life-threatening disease conditions, either for myself or someone under my guardianship.

    I understand that no recommendations are being made for me to discontinue any treatment being provided by any other health care professional. It is important that I maintain regular visits with my primary care physician and medical specialists as appropriate, to ensure proper medical care.

    Medical Disclaimer

    Michelle Gamble is not a medical doctor or other licensed health care professional. Consultations are not a substitute for medical care and do not include diagnosing or treating disease. Educational consultations in nutrition can serve as an excellent adjunct to a medical doctor’s treatment and are intended to expand a client’s consideration of available options and are intended to assist with compliance with any medical care a client may be receiving as well as assist in the use of natural means to support health.

    No aspect of a consultation should be understood as a basis to avoid any diagnostic work-up or discontinue any medical treatment. Clients should follow-up with their physician to discuss any modifications they intend to make to their health protocols, to evaluate any testing results or to change protocols as necessary.

    In appropriate cases, Michelle Gamble may make suggestions for herbal or nutritional supplements. These interventions are provided to support wellness or help with symptoms such as headaches or digestive distress that have been evaluated by a physician. Some of the nutritional, herbal and other methods recommended by Michelle Gamble are considered to be complementary, alternative, or holistic care, and may not be accepted by the larger community of medical physicians.

    Michelle Gamble provides non-medical meal plan consultation and advice, which can include education about nutrition, personalized whole foods and dietary recommendations, meal plans, lifestyle modifications, weight loss programs, advice about exercise and coaching about lifestyle changes supporting greater health and function. Recommendations may include herbal and nutritional supplement such as vitamins, minerals, herbs, amino acids and fatty acids. Michelle Gamble is not a licensed dietician or nutritionist.

    Health and nutritional mentoring supports clients who wish to cultivate positive and healthy lifestyles. The mentoring relationship assists clients develop understand their needs, develop health goals identified by the client or by their physician or other licensed professional. The mentor provides education about health options the client can explore with their physician, other health professional or on their own as appropriate. Mentoring encourages self-health management to assist clients formulate their health goals and devise and follow strategies to implement lifestyle and behavior changes. Mentoring and educating about healthy choices and available resources is tailored to a client’s particular needs so that they may make informed choices about their health options. Choices are driven by the client’s perception of their needs and any health goals. Mentoring offers support; questions regarding the diagnosis or treatment of any health or nutritional condition should be directed to the client’s physician, nutritionist or other health care professional.

    Clients may wish to explore dietary supplements on their own, which can be a valuable support for health. While herbs and botanical products are generally available over-the-counter and are considered safe based upon their long history of use, many of them have not been widely tested. The historical record and modern research indicate that herbs and supplements most often used to support health have a good safety record. Similarly, confirmed cases of herb, nutrient and drug interactions are rare though risks are not entirely understood. Herb, nutrient and drug interactions can occur.

    Michelle Gamble graduated in 2004, with a Masters and Doctorate in Naturology. She has completed certification in Colon Hydrotherapy and numerous hours of training in Functional Endocrinology and Blood Chemistry. She is currently under the mentorship of Dr. Ritamarie Loscalzo in the Institute for Nutritional Endocrinology.

    Risks/Supplement Safety

    Your mentor will research potential interactions and avoid herbs or nutrients that may interact with drugs, however research is still emerging and there may be unknown interactions. Adverse events can occur after using any active substance, including an allergic response. Negative reactions to natural remedies may include rare allergic reactions, including headaches, itching, hives, difficulty breathing, and very rarely, even shock or death. While unlikely, clients choosing to take products could have an adverse reaction or experience a reduction or increase in the effect of medications. This can have serious consequences for some medications, such as for the control of high blood pressure, blood sugar or control of bleeding/clotting. Clients should let their physician know what herbs or other dietary supplements they are taking, particularly prior to surgery or other procedures. Clients should discuss any concerns with Michelle Gamble and the primary physician as appropriate about any adverse effects or reactions.

    Managing Risk

    To reduce risk it is imperative that you disclose to your mentor:

    1) all medications, supplements and herbs currently in use,

    2) any liver or kidney disease (past or present),

    3) any allergies,

    4) if you plan to become pregnant or are currently pregnant or breastfeeding.

    It is important to stay within the recommended dosage. Any side effects or suspected supplement/drug interactions should be reported directly to all health professionals involved. It is also advisable to stop taking herbs and supplements seven (7) days before and after a surgical operation, and/or in the event of being prescribed a new medication.

    Before beginning any exercise program, clients with medical conditions or who have not exercised in some time should obtain medical clearance before beginning any exercise program. Exercise programs always contain some risk of injury or trauma if done incorrectly, in excess, or because of underlying medical conditions.


    Notice to Pregnant Women: All female clients must alert Michelle Gamble/Sankofa Healing and Enrichment, Inc. if they are pregnant or breastfeeding or suspect they could become pregnant to enhance the safety of any lifestyle changes, nutritional and herbal product recommendations and to allow any appropriate referrals can be considered.

    No Guarantees: Like any effort to improve health, consulting is an art as well as a science. No guarantees are made that a client will gain any benefit or not suffer any adverse consequences.

    Like many interventions, some nutritional and natural remedies may not have not been subjected to rigorous scientific study and there are wide individual differences in responses to these services. The responsibility for improvement lies with the client; consultations are merely a catalyst for change.

    Important Insurance Notice: Michelle Gamble’s services are not covered by health care services and are not reimbursed by insurance, Medicare or any other third-party payor. Payment in full (currently waived for internship nutrition hours) is required at each visit. Clients agree not to submit claims for these services, are responsible for payment even if an effort is made to obtain reimbursement that is denied, whether because services are “non-covered” or “not medically necessary.”

    Cancellation Policy

    Office Policies: At least a 24-hour cancellation is required to remove the reserved session time. If a client repeatedly cancels in less than 24 hours or is a "no show" to sessions, the waived session opportunity will be cancelled for this client.

    Informed Consent for Minors

    I certify that I am the parent or legal guardian of the child/ward and that I have lawful custody for the purposes of authorizing health care consultations and for the release of protected health information. To the best of my knowledge, there is parental agreement about undergoing this consultation. In the event I am or become separated or divorced or any circumstances arise under which a parental disagreement over this authorization becomes an issue, I will hold Michelle Gamble harmless.

    I hereby authorize consultation or mentoring in wellness and lifestyle activities from Michelle Gamble/Sankofa Healing and Enrichment, Inc. I understand and agree to the financial and other terms set forth above. I understand the nature of this consultation, including the risks of possible adverse reactions. I have been adequately informed, and my questions have been satisfactorily answered. I am solely responsible for the decision to see Michelle Gamble/Sankofa Healing and Enrichment, Inc. I represent that I am seeking assessment and consultation to further my own health and for no other reason. I do not represent a third party and sign this voluntarily.

  • Clear
  •  -  -
    Pick a Date
  • Privacy Notice

  • Privacy is important and records will be held confidential unless the client signs a release to other caregivers or to obtain a client copy. Sankofa Healing and Enrichment, Inc. will not use or disclose your medical information for any purpose other than as provided by your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to Sankofa Healing and Enrichment, Inc. at the address below.

    3801 Leane Dr.

    Tallahassee, Fl 32309

    Please authorize the following according to your preferences:

    Internet and Email Communication

    If consultation occurs over Zoom or other video chat services, clients should understand that while its communications are encrypted, Zoom is not considered a secure patient web portal. No guarantee can be made that the Zoom or other service protects users’ data or the content of communications or that it is secure from third-party “hackers.” Further, e-mail is not a secure and confidential method of communicating health information. While Sankofa Healing and Enrichment, Inc. will take reasonable precautions with the information under their control, interception or misuse of client communications over Zoom, email, or telephone, while unlikely, are possible. Clients agree to assume the risk and accept the consequences of such breaches. Sankofa Healing and Enrichment, Inc. shall not be liable for any breach of confidentiality that may result from the use of e-mail.

    E-mail should not be used for urgent matters and clients should contact 911 or visit the nearest emergency room if feeling unsafe or experiencing a life-threatening emergency. E-mail communications may be made part of my permanent health record and would be accessible to anyone given access to those records. Permission for communication via e-mail made be made by notice in writing. I hereby give permission for Michelle Gamble to email nutritional recommendations or coaching advice, and reply to my messages via e-mail including any information that she deems appropriate, that would otherwise be considered confidential.

    You should understand the following policies with regard to how we treat your personal health information:

    1) We cannot release information to family members, other than parents or legal guardians, even if they are involved in your care, without your written permission.

    2) In order to ensure quality of care, records are occasionally reviewed both internally and by outside consultants in legal, clinical, record keeping and other concerns that affect the quality of the services we provide. Only necessary information is accessed, and any such review is performed by professional staff working under the condition of confidentiality.

    3) If you wish to limit the nature of information that is released, or the parties noted above to whom information may be provided, please inform Michelle Gamble to discuss these limitations. In some instances, Michelle Gamble may not be in a legal position to honor requested limitations, or there may be consequences that you need to be aware of, such as limitations upon receipt of insurance payment or upon the quality of care delivered. It is best to discuss any such concerns in advance.

    4) You may revoke authorization for the future release of information in writing. We may in that event, however, decline to provide further treatment.

    5) We may be required by law, in some cases, to make disclosures of your record that you have not authorized. Examples are subpoenas in criminal or civil litigation, or requests/surveys by licensure agencies or the U.S. Department of Health and Human Services.

    6) Because Michelle Gamble is not subject to HIPAA, Michelle Gamble will continue long-established and useful business practices, such as providing you with appointment reminders, notifying you of lab results, or using sign-in sheets, but will take steps to do so in a fashion that takes your privacy expectations into account. Please inform staff of any limitations you would like us to honor in this regard.

    7) While the records of the care we provide are our property, we will make them available for your inspection and provide copies. Michelle Gamble reserves the right to charge a reasonable fee.

    Please acknowledge review of this notice and your authorization and management of health information as designated by signing below.

  • Clear
  •  -  -
    Pick a Date
Now create your own JotForm - It's free! Create your own JotForm