Agreement for Services (Peacequest Energetics)
This form is required for clients entering service. It is needed for insurance purposes and for our mutual protection.
Peacequest Energetics is a service organization owned and operated by Laurel Batterham. I am a Certified Clinical Practitioner of Eden Energy Medicine, with a background in Trauma counselling. Clients can choose from an array of modalities including: *
Required
These interventions can be very effective for physical, emotional or mental issues. However, they are considered "alternative" or "adjunctive" or "complementary" and thus are not usually eligible for reimbursement by extended health plans. Payment is therefore required at the time of service, and you may be billed for appointments missed without reasonable notice.
Services are completely confidential, with the following exceptions:
1. Child abuse must be reported.
2. Suicidal or homicidal intent must be reported.
3. Court Subpoenas will be honoured.
4. Reasonable peer consultation (with my colleagues) will be required from time to time to improve quality of service. Names will not be used.
Advocacy services are limited to supported self-advocacy. We are not able to intervene for you with authorities.
Please indicate that you understand and agree to the above conditions.
Signature ____________________________________ *
Your answer
Date _________________________________________ *
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You can either submit online, or you can print out this agreement, sign it and bring it to your first appointment. You could also scan it in and email it to me at laurel@peacequestenergetics.com.
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