Cerebral Sports - Respect * Trust * Results

 
Informed Consent/Refund Policy
 
Welcome to CerebralSports.  Thank you for choosing me as a member of your solution team.  Before we get would like to make sure that you have sufficient information about me and my practice to feel comfortable entering into a working relationship.  Please read and sign this statement and let me know if you have any questions or concerns.

 
As an Energy Medicine Practitioner, I assess and balance the subtle body energies.  I invite gentle re-connections between body energy access points, employ Meridian Tapping Techniques, and engage the energies of   Energy medicine complements all other traditional medical and holistic and stands alone as a system of self-care.  Energy medicine can bring balance to the energetic patterns of physical illness and emotional or mental distress, and also promote high-level wellness, prevention of disorders, and peak performance.  As an energy medicine practitioner, I work with the subtle energies, and do not offer diagnosis, treatment or cure for any physical, mental or emotional health care problem, disorder or illness, nor do I make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies.
 
As a Certified Myoskeletal Therapist. I am trained in the use of safe and gentle hands-on techniques to invite your energies to return to balance.  Clients remain fully clothed, and I recommend you wear comfortable, non-restrictive clothing to your sessions.  I offer a minimal amount of massage therapy, focusing primarily on subtle energy balancing through light touch and education.
 
What to Expect: You are entirely unique, so the pace of your progress towards your goals will also be unique.  Since the experience of wellness in body, has direct correlations in subtle energy fields, addressing subtle energies has the potential to clear the way for deep restoration.  Essentially, your wellness is an inside job, and I make no claims about what your individual outcomes will be a long the way.  I act as an ally on your healing journey and help you discover the nest steps in your process.
 
You are in Complete Control - of the pace of your progress.  I will teach you energy balancing techniques that can use every day to enhance and extend the benefits of our session work.  you decide how often and how many sessions you wish to partner with me.
 
Session Cost:  My hour sessions are $150.00, payable by cash or check only, either pre-paid or payable at our session.  These fees are subject to change, and you will be given advance notice if I change them.
 
Financial and Late Policies
 
1.  Payment for services is due at the time of services are rendered unless other arrangements have been made.

2.  I accept cash and checks only at this time and you can pay online with a card.

3.  Call 24hrs. prior to appointments in order to avoid being charged for the appointment.

4.  Please be on time.  If you are late, your session may be shorter in order for me to honor other clients.  You will still be responsible for the full time you have scheduled.

5.  Returned check fees are the financial responsibility of the client.

6.  Please understand that your insurance is an agreement between the insurance company and you.  If you choose to seek reimbursement, it is your responsibility to know what is required by your insurance company to do so, including the necessity f referrals for Myoskeletal Alignment Therapy.  Please understand that wellness prevention or maintenance are not services covered by most insurance companies. 

7.  I am NOT a participating provider in Medicare, Medicaid or any other government sponsored programs or insurance plans.

8.  You are responsible for all services provided at the time of treatment and take full responsibility for all bills incurred for treatment.

Unused sessions. Your sessions never expire, so if you achieve your goals in fewer sessions you may save your unused sessions for a future issue, or for tune ups. You may also transfer your sessions to friend or family member. 
 
Refund Policy. If you decide to seek a refund for unused sessions, your used sessions will be prorated against your package at the single sesssion rate for the first three used, and 80% of the single session rate for any sessions in excess of 3 used. (see my rates page for further information.) Per the above Cancellation Policy a session cancelled with less that 24 hours notice constitutes a used session and is not eligible for refund. Session cash values are valid for up to six months from date of purchase; after that, unused session can be used or transferred, but are no longer eligible to be refunded for cash value.
_____________________________________________________________________
 
 
 
HIPPA and NOTICE OF PRIVACY PRACTICES
 
The Health Insurance Portability and Accountability Act (HIPPA) was established by to establish rules concerning the use and protections of Medical and Health Information.  The rules are intended to provide standard privacy protections for your medical information.  I regard the privacy of my patients as a central part of my mission to serve the needs of the patient first.  Private controlled use of your information is essential to your care.  the Notice of Privacy practices provides you with information explaining how I use your medical information.  I acknowledge that I have been offered a copy of the Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act. I understand that this acknowledgment means only that I have received the notice and in no way affects the care I receive.
 
Initials_______________
 
------------------------------------------------------------------------------------------------------------------------
 
 
PATIENT RESPONSIBILITY
 
I realize that I am primarily responsible for determining the course of my health journey.  I understand that when energy blocks are freed there can be accompanying shaking, transitory physical discomfort, and emotional releases.  I have been advised that most sessions result in a client's feeling more relaxed and centered; occasionally the energy disturbances that are released require extra attention to assist the systems to reach of comfort and balance, and it is my responsibility to communicate any such reactions to my practitioner.  I have the right to refuse any procedure and will notify my practitioner IMMEDIATELY if I have any concerns during an energy session.  I am aware that any verbal discussions are meant only to suggest options.  If at any time I feel I have concerns regarding my mental well-being, it is my responsibility to seek appropriate treatment from a qualified mental health care provider.  I will notify Herman Johnson for any changes regarding my health status that may impact my plan of care.  If Herman Johnson recommends that I be assessed by a medical professional, and if I choose not to, I understand that scheduling our energy session y be delayed until I do so.
 
Initials_______________
 
 
_____________________________________________________________________
 
 
LIMITS OF PRACTICE
 
I understand that Herman Johnson does not diagnose or treat physical, emotional or mental illness.  I understand that Herman Johnson assesses and balances the subtle body energies that pattern physical, emotional and mental well-being.  I acknowledge and confirm that my treatment was explained prior to the service being performed.  I understand and consent to body energy system assessment and subtle energy balancing which may include a wide variety of Energy and Meridian Tapping Techniques.  I understand and acknowledge the acceptable alternatives and risks associated with the proposed treatment.  I understand that most people report significant progress towards their goals from working with an Energy Medicine Practitioner, there are no guarantees of outcomes.  Each party agrees to hold harmless the other party and agents, officers, and employees from and against any and all liability, expense, including defense costs and legal fees incurred in connection with claims for damages of any nature whatsoever including but not limited to, bodily injury, death, personal injury, financial or business losses, or property damage arising from such party's performance or failure to perform in obligations.
 
Initials_______________
 
 
_____________________________________________________________________
 
 
I HAVE READ AND CONSENT TO ALL THE POLICIES AND INFORMATION STATED ABOVE.
 
 
Print Name______________________ Sign _____________________ 

Date:______
 
 
 
________________________________________________________________________
 
 
NEW CLIENT INFORMATION                                                      Date:___/___/____
 
Name:__________________________________________________________________
 
Mailing Address:__________________________________________________________
 
City:____________________ _______State:_________________ Zip_______________
 
Which number is to contact you by (check number).
 
Are confidential messages ok? ___y ___N
 
Only provide contact numbers you would like me to use.
 
Please update me on changes to your contact information.
 
Home #:_____________  Cell#:_____________
 
Work#:____________ Email_________________________
 
Age:_______ DOB_____/_____?_____ Gender: _____
 
Emergency Contact Name________________ Relationship:_______ Phone__________
 
Emergency Contact Name_________________Relationship_______Phone__________
 
How did you find me?______________________________________________________
 
Referred, by? ___________________________________________________________
 
May I thank the for the referral? ___Y___N
 
________________________________________________________________________
 
 
Significant Stress Incidents:  Please note accidents, injuries, surgeries, and traumas, and the year they occurred.
 
Event:____________________Year:____     Event:_____________________Year:_____
 
Event:____________________Year:_____    Event:_____________________Year_____
 
Event:____________________Year:_____    Event:_____________________Year_____
 
My primary goals in my life and health are now:_______________________________________________________________
 
___________________________________________________________________
 
___________________________________________________________________
 
 
___________________________________________________________________
 
 
Release of Records
 
Provided I am informed it is necessary, I consent to the release of any confidential information relating to me or my child, if the release of that information: a) follows a statuary requirement, a Court Order or a legal duty; b) is a professional psychologist, a clinician or a medical Practitioner as part of a referral process initiated by either me or Herman Johnson; c) is for the purpose of discussing my treatment history, or that of my child, with my medical practitioner or any former clinician or psychologist who has provided services to me or my child, d) may, in the opinion of Herman Johnson, prevent the commission of a serious crime and/or harm to a third party and/or harm to me or my child; or e) is reasonably required to secure payment for charges incurred by me or on my behalf if applicable.
 
I agree that I am responsible for my actions and by signing this, agree to these terms.  I give permission to Herman Johnson to share stories of my healing journey without using my name. 
 
By completing and signing this form, I affirm that I have provided accurate information.
 
 
Client Signature__________________________________________Date____________
 
 
Printed Name___________________________________________________________