I am employing the counseling services of Chamila Edussuriya solely in her professional capacity as in Integrative Health Practitioner with Homegrownurban,LLC so that I can obtain information and guidance about health factors within my own control (diet, nutrition, and related behaviors) in order to nourish and support my (and my family's) health and wellness. I understand that Chamila Edussuriya is an Educator and does not dispense medical advice, diagnose disease, nor prescribe treatment. Rather, she provides education to enhance my knowledge of health as it relates to foods, and behaviors associated with eating. While nutritional and botanical support can be an important complement to my medical care, I understand nutrition counseling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider.

I acknowledge that I have been advised to consult a Physician before undergoing any dietary or food supplement changes. Any recommendations suggested for changes in diet, including but not limited to the use of food supplements are entirely my responsibility. Nutritional evaluation provided in counseling is not intended for the diagnosis of disease. Rather, it is to determine support in meal planning for my family. These assessments are intended as a guide to developing an appropriate health-supportive program for me (or my family), and to monitor my progress in achieving these goals. Medical records, personal information and history divulged in session to Homegrownurban, LLC will be kept strictly confidential unless I consent to sharing my medical and nutritional information by way of a signed release.

I hereby accept all risk to my health and/or injury or death that may result from such participation and I hereby release and hold harmless Chamila Edussuriya, her employees and representatives from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in nutrition counseling, whether caused by negligence of Chamila Edussuriya, her employees, or representatives, or otherwise. I further agree to indemnify and hold harmless Chamila Edussuriya and her employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in any consultations, programs or workshops with Chamila Edussuriya and Homegrownurban LLC.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT

OCCURS WHILE PARTICIPATING IN NUTRITION COUNSELING AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION.