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861 North Vista Street!
Los Angeles, CA 90046!
310-384-5542 [email protected]
Remote + In-Person Individual Weight Loss Package Contract (8-weeks)
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❑ Dates: ______________ to ______________
Program Description
Weight Loss Intensive (WLI) individual package includes:
2 in-person individual weight loss counseling appointments with body composition analysis
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2 remote individual weight loss counseling appointments via Skype or phone (in person if prefer)
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Electronic food tracking surveillance with feedback
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Electronic weight tracking surveillance
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Email check-ins between appointments
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Appointments are scheduled once every two weeks, and include four weight loss-counseling sessions with a
Registered Dietitian specializing in weight management.
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Individual Meetings
Individual counseling sessions vary and may target specific areas possibly slowing down weight loss, which
may include external/self sabotage, physical inactivity, negative self talk and emotional eating/night eating/
mindless eating/binge eating. Sessions may also include planning for high risk situations where unhealthy
eating is likely, development of individualized eating plans, setting macronutrient and calorie goals, reviewing
food records and eating trends, and/or body composition changes. Goals are individualized and specific
products may be recommended.
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Consultations with Physician
It is expected that you make arrangements to be followed by your own personal physician to ensure your
medical safety. If you do not schedule and keep these appointments, you may jeopardize your health, safety,
and continuation in the program.
Program Cost
The cost of the Weight Loss Intensive package is $500 for 8 weeks. You may divide this payment
monthly at $250 per month for a total of $500 due payable at the beginning of week four. The initial weight
loss counseling appointment is not included in this package and is required prior to initiating the package.
Initial Weight Loss Counseling Session
If you are a new patient, you will need to make and schedule an initial individual appointment prior to
initiating the package. This session is designed to assess your specific eating challenges and begin to
develop together a plan that is individualized and suitable to your lifestyle, disease states/conditions and
preferences. This appointment is not included in the package.
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Program Not Covered by Insurance
Please be informed that the services involved are usually not covered or reimbursable by any health
insurance policy or other coverage. Therefore by signing this agreement, you accept financial responsibility
for the amount of this program.
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Refunds and Missed Appointments
In the event you do not complete the program, we will NOT issue any refunds for the remaining sessions and
services. Should you need to miss a session, please make best efforts to problem- solve alternative
attendance in advance. All appointments must be made within the 8-week period.
Please note that Change My Eating, Inc. accepts cash, checks or major credit cards as methods of payment. You
must sign below and pay the total amount set forth above on or before your first session.
Please sign below if you have read, understand and agree to the terms set forth in this letter of agreement.
Thank you for choosing Change My Eating, Inc. for your healthcare needs.
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Signature of Patient or Responsible Party
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Date
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Printed Name
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Date of Birth
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