Daniela Simeone, MA
Reconnective Healing Foundational Practitioner®
Reconnection - Certified Practitioner®
Transformational Coach and Integrative Health Care Practitioner

14579 Grand Ave, Suite 100
Burnsville, MN 55306

As of July 1, 2001, Minnesota’s Freedom of Access to Complementary Care Law (Statute Chapter 146A) requires that you receive and acknowledge that you have received by your signature on this form, the following information prior to your treatment.

Daniela Simeone, MA, hereafter, “the practitioner” has the following education, degrees, training, experience and qualifications:

1997-now Transformational Coach and Integrative Health Care Practitioner in private practice
2015-now Reconnective Healing® Foundational Practitioner & Reconnection® - Certified Practitioner
2015 Reconnection® - Certified Practitioner Program & Practitioner Certification
2015 Reconnective Healing® Level II: Reconnective Healing Foundational Practitioner Program
2003-now Reconnective Healing™ Practitioner
2003 Reconnective Healing™ Levels I/II: The Basic Truths & Frequencies of Healing
2013 Certified Polarity Resolution Process Facilitator
2012 Self I-Dentity through Ho’oponopono
2010 Certified SAI Facilitator
2005-2009 Certified Practitioner of Frequencies of Brilliance Practitioner Levels 1-7, Intro Talk & Demo
and Workshop Presenter
2004-2005 Guided Self-Healing Year 1 Teacher Training Program, Practice Group Leader & Supervisor,
Intro Talk & Demo Presenter
2003-2005 Guided Self-Healing Practitioner Training Program - Year 1 and 2
2001 Certified Practitioner of High Touch® Jin Shin
2000 High Touch® Jin Shin Levels I-III
2003-2008 Certified Practitioner of Healing Touch
1999-2002 Healing Touch Levels I-IIIB
1999 Therapeutic Touch Levels I-III
1997-now Guided Imagery/Visualization, Meditation and Self-Healing Group Facilitator for Adults and
1992-1997 Completed all course & internship requirements for PhD in Clinical-Counselling Psychology
1989-1992 Master of Arts Degree in Social and Personality Psychology
1985-1989 Specialized Bachelor of Arts Degree in Psychology


Under Minnesota law, an unlicensed complementary and alternative health care practitioner may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis from a licensed physician, chiropractor, or acupuncture practitioner, or services from a physician, chiropractor, nurse, osteopath, physical therapist, dietitian, nutritionist, acupuncture practitioner, athletic trainer, or any other type of health care provider, the client may seek such services at any time.

The practitioner considers this Client Bill of Rights as a Professional Code of Ethics for her practice. The practitioner self-monitors to ensure the client's rights are upheld and she encourages clients to take personal responsibility in communicating their questions and concerns right away, knowing the practitioner values their input and aims to deliver ethical professional integrative healthcare services.

If the client has a question, concern or complaint about the care or services received, the practitioner urges the client to communicate them immediately at the time these come up and/or when they are receiving the service. If these come up sometime after the session is complete, the client is invited to contact the practitioner as soon as possible. The practitioner will address the client's concerns in a timely manner and do all that is appropriate and possible to reach a satisfactory resolution.

Office of Unlicensed Complementary and Alternative Health Care Practice:
If the client has questions or complaints about an unlicensed complementary or alternative health care practitioner, the client may also contact:
Minnesota Department of Health
Health Occupations Program Office of Unlicensed Complementary and Alternative Health Care Practice
Mailing address: PO Box 64882, Saint Paul MN 55164-0882
Phone: 651-201-3721 Fax: 651-201-3839

Fees and Billing Methods:
Reconnective Healing® - Fee per session: $120
The Reconnection® - Fee per two-session process: $333
Transformational Coaching - Fee per session: $120
Limited Time 3-Session Package Offers – Varying website fee specials are subject to periodic changes at practitioner’s discretion.
The practitioner expects payment in full prior to the provision of in-person, telephone, Skype or distance/remote healing services. Methods of payment are cash, credit card, debit card or PayPal.

The practitioner must receive notice of cancellation 24 hours prior to the scheduled session time. Clients cancelling appointments less than 24 hours prior to session are responsible for and will be charged the full session fee.

The practitioner’s services are not covered by insurance. The practitioner does not accept Medicare, medical assistance, or general assistance medical care.

The client has a right to reasonable notice of changes in services or charges.

Theoretical Approach Used by the Practitioner in Providing Services to Clients (brief summary in plain language):
The practitioner’s services are complementary to medical and other health care modalities. Services are intended to work in harmony with all health care services that are part of the client’s healing/health care team.
Reconnective Healing®, The Reconnection®, Transformational Coaching and Integrative Health Care Modalities are part of a non-invasive healing approach. The practitioner interacts with the Reconnective Healing® Frequencies and the Universal Field and acts as a catalyst for the client to reconnect to their own innate ability to heal and return to an optimal state of balance, health and evolution. Ultimately, all healing is self-healing.
Reconnective Healing®, The Reconnection®, Transformational Coaching and Integrative Health Care Modalities are not medical treatments or procedures, and they are not substitutes for medical treatment. Clients are solely responsible for seeking their own medical advice and care. The practitioner does not diagnose, treat, prevent or advise about any medical symptom, condition, illness or disease of any person when practicing Reconnective Healing®, The Reconnection®, Transformational Coaching and Integrative Health Care Modalities. The practitioner does not make any promises or guarantees to clients about the results of Reconnective Healing®, The Reconnection®, Transformational Coaching and Integrative Health Care Modalities.

The client has a right to complete and current information concerning the practitioner's assessment and recommended service that is to be provided, including the expected duration of the service to be provided.

Clients may expect courteous treatment and to be free from verbal, physical, or sexual abuse by the practitioner.

Client records and transactions with the practitioner are confidential, unless release of these records is authorized in writing by the client, or otherwise provided by law.

Clients have the right to be allowed access to their own records and written information from records in accordance with sections 144.291 to 144.298.

Clients are to be aware that other services may be available in the community. Information concerning other services is available by asking the practitioner, the provider who referred you to this practitioner or the following practitioner database on the web: - Practitioner Directory.

The client has the right to choose freely among available practitioners and to change practitioners after services have begun, within the limits of health insurance, medical assistance, or other health programs (as applicable).

The client has a right to coordinated transfer when there will be a change in the provider of services.

The client may refuse services or treatment, unless otherwise provided by law.

The client may assert the client's rights without retaliation.
(b) This section does not apply to an unlicensed complementary and alternative health care practitioner who is employed by or is a volunteer in a hospital or hospice who provides services to a client in a hospital or under an appropriate hospice plan of care. Patients receiving complementary and alternative health care services in an inpatient hospital or under an appropriate hospice plan of care shall have and be made aware of the right to file a complaint with the hospital or hospice provider through which the practitioner is employed or registered as a volunteer.
(c) This section does not apply to a health care practitioner licensed or registered by the commissioner of health or a health-related licensing board who utilizes complementary and alternative health care practices within the scope of practice of the health care practitioner's professional license.

Acknowledgment by Client *
Prior to the provision of any service, a complementary and alternative health care client must sign a written statement attesting that the client has received the complementary and alternative health care client bill of rights.
Signature *
Please type your full name below. This represents your signature and it acknowledges you have read and understood the Complementary and Alternative Health Care Client Bill of Rights.
Your answer
Date *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service