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Disclosures & Informed Consent Policies:
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 of Your Information:
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 b
e 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.
Scopes 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, relaxation, 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.
The statements herein are not intended to diagnose, treat, or cure any medical or mental health
condition, and are not intended to replace a previously prescribed or recommended allopathic,
homeopathic, naturopathic, mental health, or other treatment plan. If you are currently under another
practitioner's care, Client Self-Responsibility compels you to take care of and honor yourself by
consulting with your practitioner before making any changes to your treatment plan.
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 & Payment:
The base-session length for coaching sessions is 2-3 hours. The base-session
length for bodywork is 2 hours. The base-session length for injury-rehab-specific bodywork is 1 hour.
A fee of $25 is added for each 15-minute block beyond the base-session length.
Interim, 15- to 30-minute phone or email check-ins between scheduled appointments 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 Youniversoul's discretion. Gift Certificates
are available for full-length coaching or bodywork sessions, and are generally valid through the end of the calendar year.
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
methods are local checks or via PayPal for credit/debit cards (VISA, MasterCard, or American Express).
Checks should be made payable either to “Adele Cox,
MA, CMT” or “Youniversoul Health & Wellness” (your choice). A $25 processing fee may be charged for checks returned by the bank.
Cash is strongly discouraged. 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. On-line pre-payment (via Paypal) and client billing 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 & Continuity:
Feel free to bring a notebook or journal (or equivalent), water (or equivalent), and any items that you choose to support your focus and comfort.
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.
Thank you for your cooperation with these policies.
For more information or to schedule an appointment, please phone or email
me at the contact information below. I look forward to meeting you.
Adele Cox, MA, CMT
Somatic Personal Life Coaching &
Depth-Oriented Transformational Bodywork
Youniversoul Health & Wellness
2305 Ashby Ave (@ Telegraph), Berkeley 94705
925.683.9039
AdeleCox@Youniversoul.com
http://www.Youniversoul.com
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