|
|
Confidentiality & Operations Policies
|
Thank you for sharing your Intake information. Please read and sign below.
Participation with Youniversoul Health and Wellness implies your understanding and agreement with these
policies; please notify Adele with any questions prior to commencement of services. For the purposes of
this policy statement, unless otherwise stated the terms “Adele Cox, MA, CMT”, “Adele”, “Bodyworker”,
“Coach”, “Counselor”, “Practitioner”, “Therapist”, and “Youniversoul” are used interchangeably. Policy
statements in quotes are obtained verbatim from other sources.
Client & Practitioner Self-Responsibility
Responsibility for one’s Self is a tenet of Youniversoul. It is therefore necessary that Practitioner
and Client agree to the following: “I agree to be 100% responsible for my growth, health, and well-
being while participating in work with Youniversoul. I also agree to be 100% responsible for
participation and creation of this work. I agree to take responsibility for my truth, my feelings and
needs, and whatever issues arise during our work together. I am completely responsible for my own life
and actions, and I enter into this work with these agreements fully in mind. I agree that I am willing
to have learning and transformation happen in ways that are totally loving and kind to me and everyone
else.” By mutual agreement we enter into this working relationship fully Self-responsible for our own
respective processes, our boundaries, and without intended harm to Self or the other.
Confidentiality
Legally and ethically, the privacy of your health record is important. All information provided within
the context of our work (verbal or written, including email and voicemail content) is considered
confidential and will not be shared with any other persons without your prior consent (such as a Release
to share information with your Doctor or other health provider), UNLESS: If, during the course of the
session “(1) there is reasonable suspicion of past or present abuse to child/elder/dependent adult; or,
(2) there is clear and immediate danger to the client or another, information will be released only to
those individuals or agencies that we are legally obliged to notify”. For example, if a clear and
present danger of client suicide is revealed, we are required to make a Mandatory Referral to protect
the safety of the client; this may mean contacting a hospital, a trusted friend or relative, or a law
enforcement agency.
Adele is not a California-licensed psychotherapist, and therefore does not have the client privilege/
confidentiality protection. This means that client records may be subpoenaed by a court of law as part
of a legal action. However, Youniversoul makes its best attempt to protect client records in these cases
per the limits of the law.
Youniversoul practitioners may consult with a qualified colleague for the purpose of gaining professional
guidance, feedback, insight, or assistance on a client case. Any such consultation will include only
anonymous reference to the client(s) and only such information as needed to present the case for
sufficient feedback. These processes help ensure that our practitioners are able to offer the highest
level of assistance and support to clients.
Scope of Practice
Adele is not a California-licensed medical or mental health provider, and no representation of such is
intended or implied. Adele is not qualified to diagnose, prescribe, or treat any physical or mental
illness, and no services of Youniversoul should be construed as a substitute for medical or psychiatric
advice, exam, diagnosis, prescription, and/or treatment. Client Self-Responsibility compels you to see
a physician, chiropractor, psychotherapist, or other qualified specialist for any mental or physical
ailment you are aware of that is out of Youniversoul's scope of competence. Any diagnoses of mental or
physical illness for (but not limited to) the purpose of insurance billing by client or practitioner,
are outside of this scope of practice.
Youniversoul services are “alternative and complementary to healing arts services licensed by the
State of California”. Coaching/counseling, and/or bodywork services are intended for the purposes of
“exploring life purpose, goal setting, learning enhancement, pain management, performance enhancement,
personal growth and discovery, self-healing, stress management,” and/or somatic self-awareness.
Youniversoul practitioners are not qualified to perform spinal or skeletal adjustments. Coaching/
counseling services may include hands-on therapeutic bodywork techniques as appropriate; any illicit
or sexually suggestive remarks or advances made by the client will result in immediate termination of
the session with liability for full payment for the appointment. Because coaching and bodywork should
not be performed under certain health conditions, you affirm that you have stated all known medical or
mental health conditions and answered all questions honestly. You agree to keep the practitioner
updated as to any changes in your medical profile and understand that there shall be no liability on
the practitioner's part should you fail to do so.
Cancellation & Late Arrival
Since Adele reserves your session time for you, prompt arrival is expected. Pre-appointment reminder
phone calls or cards are available upon your request. Late arrivals may result in decreased session
time, and full payment may be charged. Cancellations require 24 hour notice, or full charge will
assessed.
Session Pricing
The base-session length for coaching sessions is 3 hours; the base-session fee is $225. The
base-session length for bodywork is 2 hours; the base-session fee is $175. A fee of $25 may be added for
each 15-minute block beyond the base-session length. Interim, 15- to 30-minute phone check-in sessions
are highly encouraged, and are offered at no charge. A 15% outcall surcharge may be added for services
performed offsite. Special package, sale, or other discounts may be applied at our discretion. Fees are
subject to change, and “are negotiable if financially significant.”
Payment is expected for the exact amount only; gratuities/tips are graciously declined. Preferred
payment method is credit or debit card (VISA, MasterCard, or American Express). Checks are accepted,
made payable either to “Adele Cox, MA, CMT” or “Youniversoul” (your choice). A $25 processing fee may
be charged for checks returned by the bank.
No cash please. Insurance billing is not currently available.
In-person payment is preferred at the beginning of the session, but must be submitted prior to the end
of the same session. Limited client billing and on-line payment via Paypal are available by special
arrangement, but must be arranged before commencement of services. Receipts are available upon your
request.
Completion
Practitioner and Client agree that our work together may be terminated at any time without penalty
UNLESS practitioner and client have agreed upon a specific number of paid sessions, in which case,
full payment will be required at or before termination. In addition, if appropriate, Youniversoul
may refer a client to another professional for outside or more appropriate consultation or assistance.
You are under no obligation to work with a professional recommended by Youniversoul, and may choose
another professional with similar qualifications. Youniversoul receives no remuneration from any
other professional for referrals (“fee splitting” or “kick-backs”).
Operations and Continuity
Please do not bring unattended children, pets, or others requiring supervision to your appointment,
as we cannot be responsible for their safety.
Please refrain from arriving with strong odors, fragrances, or aromatic food/drinks.
Please silence or turn off cell phones, pagers, and other electronic devices upon arrival.
Please refrain from the use of alcohol, recreational or prescription drugs, or any substance which
may distract or impede your ability to be fully aware and present during your session. Also, “engaging
in any potentially dangerous or threatening behavior is prohibited”.
Youniversoul reserves the right to refer or refuse service requests that are outside our scope of
practice, inconsistent with our professional ethics, or on any other appropriate grounds.
Policy Statements are subject to change.
I have read, understood, and agreed to the Policy Statements above.
Client _______________________________________________ Date _______________
Therapist ______ Adele Cox, MA, CMT __________________ Date _______________
CONFIDENTIAL
| |
|
|
|
|
