Please fill out this Intake, Agreements and Consent Form at least 24 hours before your first appointment.

Intake, Agreements and Consent for Craniosacral Therapy/Hypnotherapy/EFT/Wellness Coaching

This form is designed to help me get to know and understand you, your goals and what contributes to your well-being. Some of the questions are more applicable for craniosacral therapy clients, while others are more applicable for hypnotherapy and EFT clients. The more you answer, the better equipped I am to support you, however most of the questions are optional. Please answer those questions that inspire you or that you feel are important for our work together.

First Name *

Last Name *

What are your preferred pronouns? *

Phone *

Email *

Street Address *

City *

Province *

Postal code *

Country *

Date of birth

Family (relationship status, number and age of children/pets)

Occupation

Names of physicians you are currently seeing

Emergency contact name, phone number and relationship:

Would you like to subscribe to my newsletter from Sea Change Wellness? *

Yes

Would you like to subscribe to my newsletter from Nourish Wellness? *

Yes

How did you hear about me?

Internet Search

Facebook

Instagram

Referral

If "Referral", who referred you?

Health and Wellness

What is your current state of physical health? (Any illness, injury, pain or something else?)

If you are experiencing a physical health challenge, please tell me a bit about it? What makes it better? What makes it worse? How uncomfortable is it? Have you sought treatment for it before, and how successful was that treatment?

Have you had any surgeries? If so, for what and approximately when?

What is your current state of mental health? (Any stress, worry, depression, anxiety or something else?)

If you are experiencing a mental health challenge, please tell me a bit about it? What makes it better? What makes it worse? How uncomfortable is it? Have you sought treatment for it before, and how successful was that treatment?

Are you happy with your current state of health?

Do you have any current or past addictions to smoking, food, alcohol, adrenaline, sugar, drugs, etc.? Are you on any medication? Please list below:

Are you currently receiving medical treatment or therapy for a health challenge (physical or mental), an illness or a disease? Please describe:

How are your energy levels?

How much sleep do you get a night? What is the quality of that sleep? Do you feel rested when you get up in the morning?

What are your eating habits? (How often, quantity, quality, processed/unprocessed?)

How much water do you drink a day?

How often do you exercise or move your body every week?

How are your stress levels? When you are stressed, where in your body do you hold tension?

Exploration Questions

What is the main objective or goal you wish to fulfill during our time together?

For you to consider these sessions a success, what outcome(s) do you need to achieve?

How will you know your desired outcomes have been achieved?

Have you had previous experience with hypnotherapy, EFT or craniosacral therapy? If so, how were those experiences? Were they successful?

Have you had previous experience with coaching / counselling / therapy? If so, how were those experiences? Were they successful?

What's missing from your life at the moment?

Have you always achieved what you wanted? If not, what has stood in your way?

What makes you laugh/happy?

What brings you down?

When have you faced a fear in your life?

Would you say you are creative? If so, what does that look like for you?

What are the ways you have fun, relax and enjoy/reward yourself?

Would you say you are self-directed or do you prefer direction/guidelines/options?

What motivates you?

What are the usual defense mechanisms or excuses you use when resisting change?

What is the best way to get you past these and ‘spark you up’ when you're stuck?

Are you dealing with anything big at the moment (for example, bereavement, divorce, relocating) which may mean it’s not the right time to make major life changes?

What are some things you find relaxing? (ocean, forest, your cozy bed, something else…)

If you have any fears/phobias or images/thoughts that make you uncomfortable, what are they? (heights, closed spaces, elevators, water, something else…)

Do you have any compulsive habits?

Do you have any kind of spiritual connection/belief system you would like to share?

Do you feel there is anything else I should know before beginning these sessions?

Is there anything I can do to help you feel safe and comfortable while working with me? Your physical and emotional safety is of utmost importance to me. Please let me know how I can support you to feel as comfortable as possible.

Agreements & Consent for Craniosacral

Therapy/Hypnotherapy/EFT/Wellness Coaching

Roles

I, the client, understand that my practitioner’s role is to support, encourage, motivate, and provide information and guidance. For craniosacral therapy clients, I understand that my practitioner will also offer me manual therapy.. My role as the client is to weigh the information and suggestions provided before taking any steps. I understand and acknowledge that my practitioner holds no responsibility for my actions. I take full responsibility for the decisions I make as well as for the consequences of those decisions. I recognize that my health and well-being depend directly on how well I care for myself, emotionally, physically, spiritually and intellectually. I realize that I am an active participant in this process of change. *

I understand and agree

I do not understand/agree

Scope of Practice

Craniosacral therapy, hypnotherapy, EFT and other energy psychology techniques are considered to be experimental or alternative clinical approaches that are still gaining acceptance within the conventional medical community. They are not yet considered to be the “standard of care” at this time, although research has been promising. I understand that my practitioner has received professional training in the clinical and therapeutic use of craniosacral therapy, hypnotherapy, EFT and other energy psychology techniques and has met the required standards for their professional certifying organizations. I understand that my practitioner is not a physician or a psychotherapist and cannot and will not make any formal diagnoses, offer prescriptions or carry out traditional psychotherapy. Therefore, if at any point in our work together, my practitioner believes that I require a face-to-face diagnostic assessment, I understand that I will have to obtain that assessment as a condition of continuing to work with them. I understand that craniosacral therapy, hypnotherapy, EFT and energy psychology techniques are not a substitute for the diagnosis and/or treatment of medical or mental health conditions by a licensed health-care professional. If I have a disorder that has been diagnosed by a licensed medical or mental health professional or a condition that should be evaluated by a licensed health professional, I understand that the services I obtain from Sea Change Wellness should be used only in conjunction with my obtaining that care. *

I understand and agree

I do not understand/agree

Emergencies

I understand that my practitioner cannot be held responsible for providing services to me in the event of a crisis or emergency situation. I understand that I can call 911 or proceed to the nearest hospital emergency room for assistance. If I am having suicidal thoughts or making plans to harm myself I can call the Vancouver Island Crisis Line at 1-800-784-2433 for free 24 hour support. However, my practitioner will do their best to continue to provide services, as appropriate, if a crisis or emergency develops during our work together. *

I understand and agree

I do not understand/agree

Guarantees

While my practitioner is hopeful that our work together will be helpful, I understand that I cannot be guaranteed a positive outcome and that my progress depends on my effort and cooperation both inside and outside of the session. I understand that any testimonials, examples, stories or information provided to me do not constitute a warranty, guarantee or prediction regarding the outcome of the use of craniosacral therapy, hypnotherapy, EFT or other energy psychology techniques for any particular issue or purpose. The testimonials are given verbatim except for correction of grammar or typing errors. People agreeing to the use of their testimonial have not received any material compensation. *

I understand and agree

I do not understand/agree

Benefits and Risks

I have discussed and understand that the potential benefits of craniosacral therapy, hypnotherapy, EFT and other energy psychology techniques can include, and are not limited to: pain relief, reduced stress/worry/anxiousness/fear, improved sleep, and behaviour change. I acknowledge that with any form of therapy there can be risks, and I assume those risks. I understand that during a hypnotherapy, EFT or wellness coaching session, I might: recall uncomfortable memories or experience uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness, because the process may require discussing the unpleasant aspects of my life. I understand that during a craniosacral therapy session I might: experience fatigue, thirst, soreness/tenderness in familiar or new locations, emotional releases, lightheadedness/dizziness, symptom aggravation, temporary ”healing crisis” (physical reaction to the movement or release of energy in the body that is ultimately beneficial). *

I understand and agree

I do not understand/agree

Accuracy of Information/Disclosure

I agree to disclose my medical history and any life conditions that may affect my craniosacral therapy, hypnotherapy, EFT or wellness coaching sessions, including medications I may be taking for depression, anxiety or any psychological or psychiatric problem, in this intake form. If my medical condition should change, I will notify my practitioner BEFORE subsequent appointments. *

I understand and agree

I do not understand/agree

Physical Contact

I am aware that craniosacral therapy is a manual therapy that involves gentle, safe contacts or “holds”. I am aware that some methods my hypnosis practitioner may use could involve safe touch to deepen the hypnotic trance in order to achieve the results connected to my goals. It is also possible that safe touch could be used in the event that I am unable to tap for myself. My practitioner will always explain ahead of time where they will use physical contact, and I can let them know if I am comfortable with it or not. My practitioner will always honor any requests not to use physical contact. This level of care is taken because touch can be a potential problem in a healing relationship if the client has a history of paranoia, has been diagnosed with borderline personality disorder, has been sexually or physically abused, has suffered from other types of trauma, or tends to dissociate or detach from their sense of self. I understand this and will let my practitioner know if I fall into any of these categories prior to my first session and I will discuss any emotional risks associated with touch that may be of concern to me. I understand that if I have any misgivings, doubts, or any negative reactions to any form of physical contact, it is very important that I let my practitioner know as soon as possible. *

I understand and agree

I do not understand/agree

Other aspects of my relationship with my practitioner

I understand that I am my practitioner's client. My practitioner will not engage in any other form of relationship (social, romantic or business) with me. Beyond the serious legal and ethical considerations, our work together will be most effective when kept free from possible outside entanglements. *

I understand and agree

I do not understand/agree

Record-Keeping, Privacy & Electronic Records Consent

I understand that my practitioner will keep brief records on each session, primarily noting the date of the session, the techniques used, and progress or obstacles observed as they relate to my goals. I understand that I am welcome to request, in writing, that my practitioner make a copy of my file available to other health-care providers. \My records will be retained for at least seven years after my last appointment, after which time my practitioner will securely dispose of them. I understand that my practitioner keeps confidential notes and client records in a secure electronic format using Google Workspace for Business, which provides encrypted storage and email services. These records are password-protected, secured with two-factor authentication, and accessible only by my practitioner. Google Workspace may store data on servers located in Canada, the United States, or other countries with strong privacy protections. While Google provides security measures that meet Canadian privacy standards, I understand that my information may be subject to foreign laws (such as the U.S. Patriot Act) if stored outside Canada. I understand that my practitioner will never share my personal information without my consent, except as required by law (for example, if there is risk of harm to myself or others, or if records are subpoenaed). I understand that my practitioner does not use email to share sensitive counselling notes. Email may be used for scheduling and communication, but it is not considered a fully secure medium. *

I understand and agree

I do not understand/agree

Confidentiality - 1

I understand that my practitioner willI protect the confidentiality of all clients. They will only release information about our work to others with my written permission, or if they are required to do so by a court order or legal subpoena. I understand that there are some situations in which they are legally obligated to breach my confidentiality and contact local law enforcement and/or social services authorities in order to protect me or other people from harm. These situations include the following: (1) If, in the course of our work together, they learn that a child, elderly person, or disabled person is being abused or is at risk for being abused, they are required to notify the appropriate protective services; (2) If, in the course of our work together, I tell them that I am considering suicide or any other serious self-injurious behaviour, or are considering violence against another person, they are required to notify the appropriate authorities to prevent such actions from taking place. These situations rarely occur, but if such a situation did occur, I understand that they would make every effort to discuss it with me before taking any action. *

I understand and agree

I do not understand/agree

Confidentiality -2

Other possible situations of note involving confidentiality are: (1) If my practitioner is asked to provide services to my spouse, partner, or another member of my family. If this is the case, we will establish in advance the limits of confidentiality. Keeping secrets generally confines a practitioner’s effectiveness, so my practitioner's policy in most circumstances is that what I say and what we do can be shared with other family members I am working with. If this is what we establish, I will not tell my practitioner anything I wish to keep secret from other family members who are receiving sessions from them. If confidential information is a concern, it may be better for each family member to work with a different practitioner. (2) If my practitioner needs to consult with other professionals about our work. During a consultation, my practitioner will make every effort to avoid revealing my identity. The consultant is also bound to keep the information confidential. If I don’t object, my practitioner will not tell me about these consultations unless they feel that it is important to our work together. *

I understand and agree

I do not understand/agree

Sharing of Information

I authorize Sea Change Wellness and its associated health professionals to collect my personal and medical information if it is necessary for our work together. In addition, I authorize Sea Change Wellness and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial appointments. *

I understand and agree

I do not understand/agree

Fee structure and payment

I understand the fee structure as outlined on the Sea Change Wellness website and agree to meet my financial obligations promptly, including paying for any missed appointment without 24 hours notice. *

I understand and agree

I do not understand/agree

Cancellation/Late Policies

I commit to being on time for my appointments, and to give a minimum of 24 hours notice if I need to cancel my appointment. I understand that if I cancel without giving 24 hours notice, it will be considered to be a missed appointment and I will need to pay for it anyway. I understand that if I am more than 15 minutes late for my appointment it will be considered to be a missed appointment, and I will have pay for it anyway, as well as reschedule it for a later time. *

I understand and agree

I do not understand/agree

Contacting My Practitioner

I understand that my practitioner is often with or preparing for work with a client, and is often not immediately available. When I need to reach them outside of our sessions together, the best way to do so is by email. They will make every effort to reply to me within 24 hours, between the hours of 8 am and 6 pm, with the exception of weekends and holidays. I understand that my practitioner is away from the office several times each year for vacations or to attend professional meetings. They will make every effort to tell me well in advance of any anticipated lengthy absences if it interferes with our session plans and to discuss other options for continuing to work toward my goals during their absence. *

I understand and agree

I do not understand/agree

Terminating Services

Normally, I will be the one who decides when my work with my practitioner will end, but I understand that there are four exceptions to this. 1. I understand that the goal of our exchanges is to help me. If, during our work together, my practitioner feels that working together is not helpful enough to me, or discovers that I am not, in fact, someone who can benefit from the work we are doing together, I understand that I will be notified immediately and our work together will come to an end. 2. I understand that in some cases if the practitioner feels it is in my best interest, they will ask me to seek out the services of a psychiatrist, psychologist, or other mental health professional in my local area for a face-to-face consultation before continuing work with me. 3. I understand that if I verbally or physically threaten or harass my practitioner, they reserve the right to terminate me as their client immediately and unilaterally. 4. I understand that my practitioner reserves the right to refuse or terminate a session if I am suspected of being under the influence of a mood-altering substance. I understand that I will be responsible and charged for full payment of the normal fee. *

I understand and agree

I do not understand/agree

Complaints

I understand that if I am unhappy with the way my work with my practitioner is proceeding, I can talk to my practitioner about it so that they can respond directly to my concerns. My practitioner will take such concerns seriously and meet them with care and respect. If I believe that my practitioner has been unwilling to listen and respond, or that they have behaved unethically, I can register a complaint about their behavior with the organizations that certify them as: a clinical craniosacral therapist (The Biodynamic Craniosacral Therapy Association of North America, https://www.craniosacraltherapy.org/), a hypnotherapist (International Medical & Dental Hypnotherapy Association. Phone: 570.869.102) and a clinical EFT practitioner (https://eftuniverse.com/) *

I understand and agree

I do not understand/agree

Exclusive Jurisdiction

I understand that the sessions I receive with Sea Change Wellness will be provided in the province of British Columbia, Canada, and that the courts of British Columbia shall have exclusive jurisdiction to hear any complaint, demand, claim, proceeding or cause of action whatsoever in connection with or arising from the sessions or any other aspect of the relationship between me and my practitioner.

I understand and agree

I do not understand/agree

Please print your full name:

By signing this form, I confirm my consent to craniosacral therapy, hypnotherapy, EFT and wellness coaching and intend this consent to cover all sessions as proposed by my practitioner to deal with the problem for which I have sought support. I understand that at any time I may withdraw my consent and craniosacral therapy, hypnotherapy, EFT and coaching will be stopped. In signing, I also HEREBY WAIVE AND RELEASE Suzanna Forest and Sea Change Wellness from any and all liability, past, present, and future, relating to craniosacral therapy, hypnotherapy, EFT and wellness coaching. *

Clear

Today's date:

For clients under the age of 19, parents/guardians can provide consent below.

Parent/Guardian, please print your full name:

By signing this form, I acknowledge on behalf of my child the terms and conditions outlined above and consent to craniosacral therapy, hypnotherapy, EFT and wellness coaching for my child and intend this consent to cover all sessions as proposed by the practitioner. I understand that at any time I may withdraw my consent and craniosacral therapy, hypnotherapy, EFT and wellness coaching for my child will be stopped. In signing, I also HEREBY WAIVE AND RELEASE Suzanna Forest and Sea Change Wellness from any and all liability, past, present, and future, relating to craniosacral therapy, hypnotherapy, EFT and wellness coaching.

Clear

*If you click on the "submit my information" button and nothing appears to happen, it means that one or more of the mandatory fields have not been filled out. Scroll through the form to locate the field that must be filled out. It will be highlighted in red.