Consent to receive Services from Healing Catalyst, LLC
Quantum Biofeedback, Jikiden Reiki, Spiritual Coaching,
Aromatherapy, or Laying on of Hands
From Julie Berg
CREDENTIALS
Licensed Quantum Spiritual Healer
Certified Biofeedback Specialist
Jikiden Reiki Practitioner
I understand Julie Berg is a Licensed Quantum Spiritual Healer qualified to help me accept Divine healing on every level of my being according to my faith and beliefs.
I understand Julie Berg is a Certified Biofeedback Specialist (CBS) who is certified to use Scio Biofeedback to help me relax and manage my stress and enhance the quality of my life.
I understand Julie Berg is a Jikiden Reiki Practitioner which may help me to relax and enhance the quality of my life.
I understand Julie may use aromatherapy with essential oils to help reduce stress and enhance quality of life.
I understand Julie may use Laying on of Hands, with or without essential oils, which is an ancient spiritual healing technique to help me relax and heal myself.
DISCLAIMER
I understand that Julie Berg is not licensed as a chiropractor, counselor, medical doctor, psychologist or psychotherapist and does not portray herself as such. I understand she will not diagnose, evaluate, treat, cure, mitigate or prevent any nutritional, medical or psychological disease, disorder or condition. I further understand that she will not advise, recommend, suggest
or counsel me on any medical, dietary, emotional or psychological treatment, condition, disorder or disease of any kind. I further understand it it is my responsibility to continue my medications and remain under the care of my primary physician.
SCOPE OF BIOFEEDBACK PRACTICE
I understand the intended purpose of the services (Biofeedback training, Reiki, Spiritual Coaching, essential oils, aromatherapy and laying on of hands) is for relaxation and muscle reeducation so I may learn to: 1) reduce my stress, 2) manage my pain, and/or 3) improve the quality of my life. I understand biofeedback training is generally considered safe, but it is possible that biofeedback may exacerbate some emotional problems or I may become drowsy, at least temporarily, during the biofeedback training sessions. Other potentially harmful side effects not yet reported may occur. I agree to advise Julie Berg anytime I feel any side effects, so corrective steps may be taken to alleviate my discomfort.
I further understand these services (Biofeedback training, Reiki, Spiritual Coaching, essential oils, aromatherapy and laying on of hands) are not a substitute for effective standard medical, chiropractic or psychotherapy treatment or veterinary treatment for my pet. Julie Berg has advised me to continue ongoing medical treatment and therapies until otherwise advised by my psychotherapist, physician or medical practitioner. I understand it is important for me to stay in close communication with my physician. I further understand it is my responsibility to ask my medical doctor for permission to undergo biofeedback training if I wear a pacemaker or have any
medical condition that may be exacerbated by relaxation.
I understand it is my responsibility to monitor the effects of these services (Biofeedback training, Reiki, Spiritual Coaching, essential oils, aromatherapy and laying on of hands) and to continue the training as long as it is beneficial to me. I will tell Julie Berg anytime I experience any discomfort during these services and trainings. I further understand that research suggests that
while most people gain considerable benefits from stress reduction training, some people may not gain any benefit. I have every expectation that this will provide me some benefit, but I understand there is no guarantee that it will.
CLIENT CONFIDENTIALITY
I understand my identity and any information about me, whether I share it with Julie Berg or she discovers it on her own, will be held in the strictest confidence, except when released by me or specifically required by law. I have the right to waive this confidentiality agreement in whole or
part at any time. I further understand Julie Berg will not acknowledge my presence or discuss anything with me publicly unless I initiate the conversation and the topics of discussion.
PAYMENT FOR SERVICES
I understand Julie Berg charges an hourly fee of $70 payable by cash, money order, check or paypal at the time services are delivered. I also understand she does not accept credit cards at this time. In the event my check is not honored by her bank, I agree to pay an additional fee for $30 for this inconvenience.
ARBITRATION
I agree that in the event Julie Berg and I are unable to reach an amicable solution to any issues between us, we both agree to accept the decision of the attorney arbitrator of the Natural Therapies Arbitration Council as the final settlement of our differences. I understand this service is provided through the Biofeedback Association of North America (BANA) at no cost to me.
CLIENT WARRANTY
By signing below, I acknowledge that I have read and understand this document, and have received acceptable answers to all of my questions about biofeedback services. I consent to receive biofeedback training from Julie Berg. I warrant I am not under duress at this time and my consent is given voluntarily and without coercion. I further understand I may discontinue
biofeedback training at any time and that I may refuse to participate in any particular or specific biofeedback training without penalty.
Client Name:___________________________________
Address: __________________________ State_______ Zip __________
Phone: __________________________
___________________________________ __________________
Client Signature Date