For your convenience please download the following forms and please read them carefully, fill them out, and sign them prior to your office visit.
Client Information Form (Download PDF)
Consent for Treatment Form (Download PDF)
Notice of Privacy Practices (Download PDF)
Consent for Bioenergetic Analysis Form (Download PDF)
Consent for EMDR Form (Download PDF)
Consent for Telehealth Consulatation (Download PDF)
Informed Consent During Covid-19 (Download PDF)
Statement of Confidentiality
It is my legal duty to safeguard your Protected Health Information (PHI).
By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures.
This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice. PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made.
I am legally required to follow the privacy practices described in this Notice. I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office. You may also request a copy of the complete Notice from me, download it, or you can view a copy of it in my office.
Workshop Cancellation Policy
I understand that life events happen and that sometimes we must change our plans. If you must cancel, please do so as soon as possible. If you cancel within 10 or more days prior to the workshop, I will refund your deposit minus $150. If you cancel your workshop with less than 10 day’s notice, you will forfeit your deposit. I do offer a one-time opportunity to transfer your deposit to one of my future workshops within 12 months of your scheduled workshop. Please contact me for details at the time of cancellation.
Your deposit is non-refundable if you do not attend or complete the workshop. My workshop presenter(s) and I are not responsible for any other costs you may incur when making workshop arrangements (such as travel, lodging, etc. unless otherwise specified).
If the presenter(s) cancel a workshop, we will issue you a full refund.