Donna Jacobs – Clinical Psychologist, M.A

I understand and acknowledge that Dr. Jodi Larry, N.D. is a registered naturopathic doctor and the Cleanse for Life program (the “CFL Program”) is a group supported cleanse intended for general well-being, to enhance my knowledge of health and wellness as it relates to foods, dietary supplements and lifestyle behaviors. I represent and warrant that I am healthy and do not have a medical condition that would prevent my participation in the CFL Program. In addition, I understand and acknowledge that Dr. Larry is not a psychiatrist, psychologist or psychotherapist. Dr. Larry is no way responsible for any personal issues or anxieties that may be triggered because of my participation in the CFL Program. I understand that it can be a detriment to my health and safety to participate in the CFL Program if I am going through any of the following: · Acute trauma · Severe mental health condition that is not currently stable · Active addiction to drugs or alcohol · Eating disorder (unless stable and I have provided a letter from my treating therapist approving participation it the CFL Program). I acknowledge that if I am under the care of a health professional or currently use prescription medications, I will discuss any dietary changes or the potential use of any dietary supplements with my doctor and will not discontinue any prescription medications without first consulting my medical doctor. In consideration of being permitted to participate in the CFL Program, I agree to assume full responsibility for any risks, injuries, or damages known or unknown which might incur as a result of my participation. Understanding the CFL Program – A Safe Environment and Confidentiality The CFL Program can be a powerful and valuable venue for healing and growth. It is a process of understanding more about yourself and others in a safe environment. You are welcome to share as much or as little about yourself while in the group, however, the more open you are the better experience you will have. Due to the nature of the CFL Program privacy and confidentiality are of the utmost concern. A safe environment is fostered and maintained by both Dr. Larry and the group members. Primary ingredients are mutual respect and a chance to create trust. Another primary ingredient for a safe environment has to do with confidentiality. Dr. Larry is bound by law to maintain confidentiality, as group members are bound by honor to keep what is said in the group in the group. Therefore, it is essential that any and all information presented and shared within the group, whether by Dr. Larry or another group member, is not to be discussed outside of the group setting with anyone for any reason. For clarity, you are permitted to share what you are learning about yourself in the CFL Program with a significant other, however you may not talk about how events unfold in group or in any other way compromise the confidentiality of other group members. I understand and acknowledge that confidentiality may be breached by Dr. Larry if a CFL Program participants discusses any of the following: (a) suicidal ideations or thoughts and Dr. Larry feels the person is at risk; (b) intent to harm him/herself or someone else; or (c) physical abuse. Dr. Larry is mandated by her board to give this information to appropriate persons in order to obtain the best care for you and those you may harm. In further consideration of being permitted to participate in the CFL Program, I knowingly, voluntarily, and expressly release Dr. Larry from any and all liabilities and waive any claim I may have against Dr. Jodi Larry for injury or damages that I sustain as a result of such participation. I and my heirs or legal representatives forever release, waive, discharge, and covenant not to sue Dr. Jodi Larry, for any injury or death caused by negligence or other acts. I have read the above informed consent and waiver and fully understand its contents. I voluntarily agree to the terms and conditions stated above.