Consent & Disclosure

(Under California B&P Code §2053.6)


Please review the following:


I understand and acknowledge all of the following:


1. Required disclosures. Andrew Kornfeld (“Educator”) is not a licensed physician or psychologist or provider of medical or psychological services. The services offered by Educator are alternative or complementary to healing arts services licensed by California and are solely educational. The services that Educator offers are not licensed by California.

Nature of Services: The nature of the services Educator will offer are as follows: educational resources, healthy lifestyle information, facilitation of health care providers, administration health coaching. This involves guiding clients to make thoughtful, manageable lifestyle adjustments to improve overall well-being and vitality. In addition, Educator may in some circumstances be providing nutritional advice or giving advice concerning proper nutrition, which means the giving of information as to the use and role of food and food ingredients, including dietary supplements.


Theory: The theory upon which the services are based is as follows: educating people on healthy living, healthy eating, exercising, and teaching clients how to facilitate better communication with their healthcare providers. The services involves attuning the client to his/her own health goals, metrics, and habits, so clients can release limiting beliefs, clarify their values, and achieve overall self-improvement.


Education, Training, Experience: Educator’s education, training, experience, and other qualifications are as follows: The Educator holds dual degrees in neuroscience and psychology from the University of California, Santa Cruz and who has previously suffered from Inflammatory Bowel Disease. He has made great improvements through lifestyle changes, however, he is not a licensed health professional and cannot give medical advice.


State law allows any person to provide nutritional advice or give advice concerning proper nutrition–which is the giving of advice as to the role of food and food ingredients, including dietary supplements.  This state law does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than one who is a licensed health practitioner to state that any product might cure any disease, disorder, or condition.


2. No Guarantee: I recognize that Educator cannot guarantee results or any specific outcomes from our work together. I am solely responsible for any action taken based on my interpretation of any information presented.


3. Right to discontinue services: I understand that Educator has the right to refuse to continue delivering services at any time for any reason.


4. No Medical or Psychological services: I am not engaging Educator for any medical or psychological services. I understand that Educator does not diagnose, treat, or claim to cure any medical or psychological condition, and that Educator’s services are not designed to replace conventional treatment methods of medical or psychological conditions. I also understand that Educator does not offer therapy for emotional or mental disorders. I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as physicians and psychologists.


5. My Responsibility for My Self-Care: I understand that any inner-directed work or reflection can bring up distressing feelings, images, thoughts and behaviors. I agree to seek medical assistance or psychotherapy or any other appropriate physical or mental diagnosis and treatment from a practitioner duly licensed (such as a licensed medical doctor or licensed psychologist) if I find that these distressing aspects create a danger for myself or for others.


6. No Hospitalization for Mental Illness: I acknowledge that I have not been hospitalized for any psychiatric condition within the last ten (10) years, nor have charges been brought against me based on my behavior.


7. Assumption of Risk: I knowingly, voluntarily, and intelligently decide to receive the services described above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Educator and his agents from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described above, or arising out of or in connection with referral to other practitioners or merchants for delivery of any services.


8. Financial Responsibility: I understand that Educator does not accept insurance or negotiate with insurers, and that Educator’s services are likely not reimbursed by any insurer. I am financially responsible for the program.


9. Arbitration: Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in San Mateo, California, before one (1) arbitrator. The arbitration shall be administered by AHLA Alternative Dispute Resolution Service Rules of Procedure for Arbitration, in San Mateo. Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. Each party has read and understood this Section (Arbitration) and understands that it thereby agrees to submit any claims arising out of this Agreement to binding arbitration, and that this dispute resolution provision constitutes a waiver of the Party’s right to a jury trial. HOWEVER, prior to either party initiating Arbitration of any dispute, the parties agree to attempt mediation of the dispute with a mutually agreeable trained mediator in San Mateo. “Trained mediator” means a professional with actual training and experience in the field of Mediation and/or dispute resolution. EACH PARTY HAS READ AND UNDERSTANDS THIS SECTION and UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, THE PARTY AGREES TO SUBMIT ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH, OR TERMINATION THEREOF TO MEDIATION AND ARBITRATION, AND THAT THE DISPUTE RESOLUTION PROVISIONS SET FORTH IN THIS SECTION CONSTITUTE A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL.