Integrative Mindworks Informed Consent
This document is intended to obtain your consent to receive my assistance and to inform you of my policies and your rights.
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Your Name *
Mindworks are designed to open doors to self-knowledge, interrupt self-sabotaging patterns of thought and behavior, and reinforce self-supporting core beliefs and habits. Our work together is a partnership forged with the common intention of bringing you to a higher state of health and well-being. Your role is to let yourself receive assistance and allow those parts of you that have been part of the problem to become part of the solution. My role is to guide and facilitate this process. Working together, we can create lasting changes that transform your life.
Please add your initials below to acknowledge that you've read the previous paragraph. *
I no longer maintain a physical office. Through either phone or video sessions, I offer optimal life counseling, lifestyle and nutrition assessment, health coaching, intuitive consulting, mind-body education, stress management training, yoga therapy, and energy therapies to enhance wellness, raise proficiency, improve relationships, and facilitate healing. As a Licensed Clinical Professional Counselor and Certified Health Coach I am qualified to diagnose and deliver non-pharmaceutical treatments for mental or emotional disorders. I will provide you with a gentle, holistic process that may or may not resolve the issue(s) you wish to work on. I ask only that you come with a sincere desire and intention to release what troubles you and a willingness to change for the better, whatever that may entail. The number of appointments and processes employed vary according to the individual needs and goals of each client.

Please add your initials below to acknowledge that you've read the previous paragraph. *
I hold a Masters degree in Counseling from the University of Idaho, am state licensed in Idaho as a Clinical Professional Counselor, and was nationally certified as a Rehabilitation Counselor. I am also a Certified Health Coach, trained through a year-long program by the Institute for Integrative Nutrition, and a Clinical Hypnotherapist trained in the 200-hour program at the Hypnotherapy Institute of Spokane and tested and certified by the American Council of Hypnotist Examiners, with over 125 hours to date of additional advanced courses in Medical and Dental Hypnosis, Hypnotherapy for Children, Solution-Focused Counseling, Dissolving Depression, Clarity Process, Dream and Symbol Analysis, Art Therapy, and Teaching Self-Hypnosis. I received Registered Yoga Teacher (RYT) status with the Yoga Alliance after earning a 200-hour certification through Integrative Yoga Therapy. Other certifications include Emotional Freedom Techniques—Advanced Studies (EFT-ADV, 125 hours), BioSomatic Movement Education (102 hours), Stott Pilates (110 hours) and Usui Reiki Master Teacher (60 hours). Additional trainings include Lowen manual therapy (100 hours), Eden Energy Medicine (60 hours), LightBody, Ziva, yogic and qigong meditation (500 hours), Medical Intuition (60 hours) and Nutrition Response Testing (20 hours). I maintain ongoing studies in advanced hypnotherapeutic processes, yoga therapy, mind/body wellness, and energy therapies.
Please add your initials below to acknowledge that you've read the previous paragraph. *
Your verbal communication and clinical records are strictly confidential except for: a) as indicated below (NOTE, Coordination of Treatment), b) information shared with your insurance company to process your claims (diagnosis and dates of service), c) information you and/or your child or children report about physical or sexual abuse; then, by Idaho State Law, I am obligated to report this to the Department of Children and Family Services, d) where you sign a release of information to have specific information shared, e) if you provide information that informs me that you are in danger of harming yourself or others, f) information necessary for case supervision or consultation, or g) when required by law.  

If an emergency situation arises for which you feel immediate attention is necessary, you understand that you are to contact the emergency services in the community (911) for those services.  After you receive those emergency services I will provide you with standard counseling and support.

Please add your initials below to acknowledge that you've read the previous paragraph. *
If you have any acute or chronic physical disorders and have not yet sought the advice of a qualified health professional about your condition, please do so before scheduling an Integrative Mindworks session.  I am happy to work with you in conjunction with your other healthcare providers and believe it is important that all your health care providers work together so you get the best possible result.
I would like your permission to communicate with any primary care physician and/or psychiatrist and/or other mental or physical healthcare practitioner whose care you are currently under, as well as your relevant family members if needed. If you prefer to decline consent no information will be shared.

You may consult with my healthcare practitioner(s) and/or family members *
If yes, names and phone numbers of healthcare practitioner(s) and/or family members
Individual sessions:

          30 minutes   $ 60

          60 minutes   $120

          90 minutes   $180

         120 minutes   $240

Prepaid packages:

      Four 60-minute sessions $420 ($60 discount)

       Eight 60-minute sessions $800 ($160 discount)

Payment in full is due prior to or at time of service.

Payments can by made via PayPal through my website or directly from the PayPal website. Your insurance company may or may not offer reimbursement. Consult them prior to our appointment if this is a concern or prerequisite for your visit.

Please add your initials below to acknowledge that you've read the previous paragraph. *
If you need to cancel your appointment, please do so by phone (leaving a voice-mail message at 208 882-8159) at least 24 hours in advance. You will be charged for any missed appointments. Emergency cancellations (less than 24 hours in advance) are handled on an individual basis.
Please add your initials below to acknowledge that you've read the previous paragraph. *
I am placing my initials below to affirm that I have read a copy of the Notice of Policies and Practices to Protect the Privacy of Your Health Information (HIPPA) published on https:/ I understand it is available for my review at any time.
Please type your name below in the box provided to serve as your electronic signature verifying your understanding of and agreement with the information and terms on this Informed Consent document.
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