Print the agreement here.
Insightful Inspirations
Leanne Holitza
Intuitive Wellness Coach & Energy Healing Practitioner
18 Garden Center Broomfield, CO 80020, Phone: (303) 881-0796
Client Agreement and Disclosure Statement
Thank you for your interest in working with me as a client either in person or at a distance using the phone/Skype/email, whichever is applicable. I am providing you with the following information so you can make an informed choice about your decision to engage my services. Please read this information carefully and let me know if there is any part you do not understand.
SERVICES OFFERED/THEORETICAL APPROACH
I offer my services as a complementary and alternative health care practitioner under Colorado’s Natural Health Care Consumer Protection Act. I work with clients in a number of areas, including, overall health, life issues, business consulting, and energy and spiritual wellness. My goal is to help my clients align with their highest potential using intuitive skills to help turn struggles and challenges into new learning and growth opportunities. My focus with a client is to work with the whole person, using a variety of complementary and alternative medicine (CAM) approaches. The CAM approaches I use primarily in my practice are based on the newly emerging field of Energy Medicine and include, intuitive wellness coaching, intuitive and past life readings, and energy-based consciousness techniques (collectively the “Energy Methods”). You have the option of using individually or collectively any of the Energy Methods I offer as part of our work together.
The Energy Methods are designed to assess where the body’s energies are blocked or not in harmony and then correct and balance the flow of these energies thereby aligning the body’s energies to boost health, vitality, and restore the body’s natural energies. With the Energy Methods, I also assess the energetic impact of how thoughts, beliefs, and emotions can influence the health and well-being of the client. The prevailing premise of the Energy Methods is that the flow and balance of the body’s electromagnetic and subtler energies are important for physical, spiritual, and emotional health, and for fostering well-being. With any of the approaches I use, I will encourage you to ask questions and provide feedback to me during the session as to how you are feeling and what you are experiencing. If you ever have questions or concerns about the nature of the theories and methods I use, please feel free to ask me for further resources or references.
Although the Energy Methods appear to have promising emotional, spiritual and physical health benefits, they have yet to be fully researched by the Western academic, medical, and psychological communities. Therefore, the Energy Methods may be considered experimental and the extent of their effectiveness, as well as their risks and benefits, are not fully known.
NATURE OF THE RELATIONSHIP
Please be advised I offer my services solely as complementary and alternative health care practitioner. You should discuss any recommendations I make during your session with your primary care physician, obstetrician, physician, obstetrician, gynecologist, oncologist, cardiologist, pediatrician, or other board-certified physician. The Energy Methods are self-regulated and the State of Colorado does not license, certify, or register complementary and alternative health care practitioners. While I have extensive experience as a healing arts practitioner, I’m not a psychologist, psychotherapist, physician, or other licensed health care professional. Under Colorado’s Natural Health Care Consumer Protection Act, I can offer my services subject to the requirements and restrictions that are fully described therein.
OUTCOME EXPECTATIONS/RISKS & BENEFITS
While clients report positive outcomes in using my services, please note that it’s impossible to guarantee any specific results and we don’t know how you will personally respond to using the Energy Methods. However, we will work together to achieve the best possible results for you. Participation in sessions can result in a number of benefits to you, including improvement and/or resolution of the specific concerns that led you to seek my services. While the Energy Methods are considered gentle and non-invasive, it’s possible in our sessions together, or on your own between sessions, to experience some physical discomfort or emotional distress that can be perceived as negative. It is also possible to experience some emotional distress and physical discomfort related to stressful experiences you may have had earlier in your life. You agree to promptly inform me if you experience any emotional distress and/or physical discomfort during our work together, particularly between our sessions. If appropriate, I can help refer you to an appropriate professional health care provider for further assistance.
OTHER IMPORTANT INFORMATION
When using the Energy Methods you understand I’m not “diagnosing” or “treating” the physical body, which is the domain of the medical field and other allied health care professionals. You understand there is a distinction between “healing” using the Energy Methods and the practice of medicine or any other licensed health care practice. Further, you understand the services I offer and the use of the Energy Methods are not intended to be a substitute for medical or psychological treatment and they do not replace the services of health care professionals. You agree and understand it is your responsibility to consult with your health care provider for any specific health care problems. Further, you understand I may suggest you contact your professional health care provider if I believe it’s advisable. In addition, you understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing any of your health care professionals or using prescribed medication, if any, without consulting with your health care professional, even if after working together it appears and indicates that such medication or treatment is unnecessary. I am covered by liability insurance applicable to any injury caused by an act or omission by me in providing my complementary and alternative health care services pursuant to this Agreement.
EDUCATION AND TRAINING
I have a Bachelor’s degree and a Master’s degree from the University of Colorado’s Business School. I have completed the Clairvoyant Program at Psychics Horizons and have studied a variety of energy techniques, including Reiki.
ACKNOWLEDGMENT & CONSENT TO RECEIVE SERVICES
By signing this document you agree that I have disclosed to you sufficient information to enable you to decide to undergo or forgo the services I offer. You have considered all of the above information and have obtained whatever information or professional advice you deem necessary to make an informed decision. By signing this document you understand I am offering my services solely as a complementary and alternative health care practitioner and our relationship is not to be construed as medical treatment, psychotherapy, psychological counseling, or any type of therapy, nor is it a substitute for these services. Due to experimental nature of the Energy Methods, you agree to assume and accept full responsibility for any and all risks associated with using the Energy Methods. You acknowledge that we have discussed and you understand, and agree to and have received a copy of my Office Policies & Procedures, which is attached hereto and incorporated herein by reference.
You understand it is your responsibility to maintain a relationship with a health care professional. Further, you understand your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. You represent that you are competent and able to understand the nature and consequences of the proposed sessions and agree to be personally responsible for the fees related thereto. You have discussed with me the nature of the services to be provided and you understand that I’m not a licensed, registered, or certified health care provider in the State of Colorado. You agree and understand that this Agreement is intended to be a complete unconditional release of liability and assumption of risk to the greatest extent permitted by law. By signing in the space provided below, you knowingly, voluntarily, and intelligently assume these risks and risks and agree to irrevocably release, indemnify, hold harmless and defend Leanne Holitza and her agents, representatives, consultants, and employees from and against any and all claims of whatsoever kind or nature, and for any loss, damage, or injury, including but not limited to, financial, personal, emotional, psychological, medical, or otherwise which you may incur arising at any time out of on in connection with your sessions.
By signing in the space below, you acknowledge you have received the information described in Paragraph (a) of Subsection 7 of Colorado’s Natural Health Care Consumer Protection Act all of which is provided in this Client Agreement and Disclosure Statement. Per Colorado law, I will keep an original signed copy of this Client Agreement and Disclosure Statement in my records for at least two (2) years.
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Client Signature Date
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If you are submitting this Agreement electronically, typing your name in the space provided above will be considered your signature and constitute your acceptance and agreement of this Agreement
© 2015 Midge Murphy, All rights reserved. Any unauthorized use of this Client Agreement is prohibited by federal law. No part of this document may be reproduced or transmitted in any form or by any means, including photocopying, for public and/or private use without permission in writing from Midge Murphy.
Insightful Inspirations
Leanne Holitza
Intuitive Wellness Coach & Energy Healing Practitioner
18 Garden Center Broomfield, CO 80020 Phone: (303) 881-0796
OFFICE POLICIES & PROCEDURES
Attachment to CLIENT AGREEMENT & DISCLOSURE STATEMENT
CONFIDENTIALITY
With the exception of special situations described below, I will keep our work together confidential. I cannot and will not tell anyone else what you have told me, or even that you are using my services without your prior written permission. You may direct me to share information with whomever you choose and you can change your mind and revoke that permission at any time.
Although I am not a licensed professional health care provider, I choose to be in alignment with general ethical standards by adhering to the following legal exceptions to confidentiality:
1. If I believe the client is in imminent danger of hurting herself/himself
2. If I believe the client is threatening serious bodily harm to another
3. If I believe that a child, elderly or disabled person is being abused
4. If I am presented with a legitimate court order to present testimony in a legal proceeding
5. If a client fails to pay for services requiring action to collect fees due
SESSIONS
All sessions are 60 minutes in length unless prior arrangements have been made.
PROFESSIONAL FEES
New Clients: $330 for initial consultation and 30 minute follow up.
Existing clients: $165 per hour session
PAYMENT
Sessions may be paid for by personal check, cash, or credit card. I do not bill through insurance so my work is on a fee for service basis. Payment is expected prior to the appointment or at the time of service, unless previous arrangements have been made. Please notify me right away if a problem arises regarding your ability to make payments.
CANCELLATIONS
Scheduling of appointments involves the reservation of time specifically for you. Please allow a minimum of 24-hour advance notice for rescheduling or canceling an appointment. The full fee may be charged for missed appointments without such notification.