Client Informed Consent & Disclosure Statement
Thank you for your interest in working with me as a client either in person, by phone, or Skype, whichever is applicable. I am providing you with the following information so you can make an informed choice about your decision to engage my services. Please read this information carefully and let me know if there is any part you do not understand. Our work together will include a shared understanding of what you hope to accomplish and agreements for supporting those outcomes. Although I will share my skills and abilities my work with you is only a resource. As an intentional and conscious participant in your growth, you will ultimately take all responsibility for and actions related to your health and well-being.
Theoretical Approach/Services Offered
In my practice I use several innovative techniques which you have the option of using individually or collectively as part of work together. I offer energy sessions, intuitive advice, sound healing, and flower essences, (collectively “Energy Medicine”) and I also incorporate restorative yoga. Energy Medicine is a collective term used to refer to a variety of treatments that are based on the use and modification of energy fields that look at the energetic influence of thoughts, beliefs, and emotions on the body. The prevailing premise of Energy Medicine is that the flow and balance of the body’s electromagnetic and more subtle energies are important for physical, spiritual, and emotional health, and for fostering well-being. As an intuitive practitioner of the healing arts, I use Energy Medicine techniques to balance my clients’ energy systems and to communicate spirit to spirit with my clients. I do not work at the level of the physical body as is customary in allopathic medicine. If you ever have questions or concerns about the nature of the theories and methods I use, please feel free to ask me for further resources or references.
Although Energy Medicine appears to have promising mental, spiritual, and physical benefits, it has yet to be fully researched by the Western academic, medical, and psychological communities and therefore, is considered experimental. The Energy Medicine techniques I use in my practice are considered “alternative” or “complementary” to healing arts that are licensed by the State of California. Although I have extensive experience in the healing arts, I’m not licensed in the State of California as a physician, psychologist, or other licensed health care provider nor are my services licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you my services, subject to the requirements and restrictions that are described fully in the attached Client Information Sheet incorporated herein by reference and made part of this Client Informed Consent and Disclosure Statement.
Outcome Expectations / Risks & Benefits
The intuitive methods I use appear to result in positive outcomes and clients have found them to be effective and beneficial. However, it is impossible to guarantee any specific results regarding your goals using any of the Energy Medicine techniques or products I offer, and we don’t know how you will personally respond to any of the Energy Medicine techniques. However, we will work together to achieve the best possible results for you.
The clinical reports from Energy Medicine show no significant side-effects when used appropriately. However, please be advised that in our work together it is possible to experience some emotional distress and/or physical discomfort or additional unresolved memories may surface related to prior life experiences which could be perceived as negative side effects. Emotions or physical discomfort may continue to arise after a session and you are encouraged to discuss such emotions or physical discomfort with me and, if appropriate, I can refer you to a licensed health care professional for further assistance.
Other Important Information
My work with you as an intuitive counselor/adviser and energy balancing practitioner is not intended to be used to diagnose, treat, cure, or prevent any disease or psychological disorder; our sessions together do not replace the advice and/or services of health care professionals. You agree to consult with your health care provider for any specific health care problems and understand that I may suggest you contact your professional health care provider if I believe it’s advisable. In addition, you understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing any of your health care professionals or using prescribed medication, if any, without consulting with your health care professional, even if after a session it appears and indicates that such medication or treatment is unnecessary. You agree to take full responsibility for your self-care in the, emotional, mental, physical, and spiritual dimensions of your life. You agree to contact me directly if you have any concerns about your experiences with your energy sessions and/or our relationship as practitioner and client.
Education and Training
I earned a Masters of Intuition Medicine (MIM) certificate, a three-year program in Intuition Medicine®, from the Academy of Intuition Medicine® and studied Sound Healing with Tom Kenyon under the auspices of Acoustic Brain Research [ABR], completed the Flower Essence Society Professional Course and I am a certified Relax and Renew Trainer® in Restorative Yoga.
Acknowledgment and Consent to Receive Services
By signing this document, you agree that I have disclosed to you sufficient information to enable you to decide whether or not to engage my services. You understand that you are freely choosing to take advantage of my intuitive counseling and energy balancing services and would otherwise have the option of using another practitioner of your choosing. You understand that your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. Further you understand the extent of Energy Medicine’s effectiveness as well as its risks and benefits are not fully known and you agree to assume and accept full responsibility for any and all risks associated with using Energy Medicine. You represent that you’re competent and able to understand the nature and consequences of our proposed sessions.
You have read and understand the above disclosure about the services offered by me and my training and education. You have discussed with me the nature of the services to be provided and you understand my services as an intuitive counselor and energy balancing practitioner are not licensed by the State of California. You agree to be personally responsible for the fees related to the services provided to me. By signing in the space provided below, you knowingly, voluntarily, and intelligently assume these risks and agree to release, indemnify, hold harmless and defend Mary Spicer and her agents, consultants, and employees from and against any and all claims of whatsoever kind or nature, which you, or your representatives, may have for any loss, damage, or injury arising out of or in connection with your sessions.
In order to use my services, California state law requires that you acknowledge receipt of the information provided in this Client Informed Consent and Disclosure Statement. I will keep an original in my records for at least three (3) years.
______________________________________________ __________________
Signature Date
© 2010 Midge Murphy. All rights reserved. Any unauthorized use of this Informed Consent is prohibited by federal law. No part of this document may be reproduced in any form or by any means, including photocopying, without permission in writing from Midge Murphy.
CLIENT INFORMATION SHEET [ Legal Information about Complimentary Medicine in California ]
In September 2003, California passed ground breaking legislation (California Senate Bill SB-577) which has profound implications for the practice of complementary and alternative forms of health care in California. SB-577 legally enables complementary and alternative health care practitioners to provide and advertise their services to California citizens. However, they must comply with certain requirements specified within the bill which has now become part of California law under sections 2053.5 and 2053.6 of California’s Business and Professions Code.
Sections 2053.5 and 2053.6 of California’s Business and Professions Code provide the following:
A. Provide access to complementary and alternative health care practitioners. You must be given information about the nature of treatment and the practitioner’s qualifications. Please ask your practitioner any question you may have about the treatment options they offer. Ask if you practitioner has been certified by a professional organization and if they belong to any professional organizations. Please tell your physician if you are receiving any alternative treatments. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet your health goals.
B. Requires unlicensed complementary and alternative health care providers to follow certain guidelines and to refrain from certain practices
C. Specifies that unlicensed complementary and alternative health care practitioners are NOT allowed to do:
Perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
Use X-ray radiation
Prescribe prescription drugs, or recommending that you discontinue drugs that were prescribed by a licensed physician.
Set fractures
Treat wounds with electrotherapy
Put you at risk of great bodily harm, serious physical or mental illness, or death
Imply in any way that he/she is a licensed physician.
D. Specifies that complementary and alternative health care practitioners MUST DO the following things:
- Provide you with a statement, written in plain language that includes the following information: (1) that they are not a licensed physician and that their services are not license by the state; (2) a brief and clear description of the kind of services they provide and the reasoning behind it; and (3) a description of their education, training, and experience.
- Ask you to sign and acknowledge that you received the above written statement, and provide you with a copy of it. They must also keep a copy of your signed acknowledgment for three years.
Theoretical Approach/Services Offered
In my practice I use several innovative techniques which you have the option of using individually or collectively as part of work together. I offer energy sessions, intuitive advice, sound healing, and flower essences, (collectively “Energy Medicine”) and I also incorporate restorative yoga. Energy Medicine is a collective term used to refer to a variety of treatments that are based on the use and modification of energy fields that look at the energetic influence of thoughts, beliefs, and emotions on the body. The prevailing premise of Energy Medicine is that the flow and balance of the body’s electromagnetic and more subtle energies are important for physical, spiritual, and emotional health, and for fostering well-being. As an intuitive practitioner of the healing arts, I use Energy Medicine techniques to balance my clients’ energy systems and to communicate spirit to spirit with my clients. I do not work at the level of the physical body as is customary in allopathic medicine. If you ever have questions or concerns about the nature of the theories and methods I use, please feel free to ask me for further resources or references.
Although Energy Medicine appears to have promising mental, spiritual, and physical benefits, it has yet to be fully researched by the Western academic, medical, and psychological communities and therefore, is considered experimental. The Energy Medicine techniques I use in my practice are considered “alternative” or “complementary” to healing arts that are licensed by the State of California. Although I have extensive experience in the healing arts, I’m not licensed in the State of California as a physician, psychologist, or other licensed health care provider nor are my services licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you my services, subject to the requirements and restrictions that are described fully in the attached Client Information Sheet incorporated herein by reference and made part of this Client Informed Consent and Disclosure Statement.
Outcome Expectations / Risks & Benefits
The intuitive methods I use appear to result in positive outcomes and clients have found them to be effective and beneficial. However, it is impossible to guarantee any specific results regarding your goals using any of the Energy Medicine techniques or products I offer, and we don’t know how you will personally respond to any of the Energy Medicine techniques. However, we will work together to achieve the best possible results for you.
The clinical reports from Energy Medicine show no significant side-effects when used appropriately. However, please be advised that in our work together it is possible to experience some emotional distress and/or physical discomfort or additional unresolved memories may surface related to prior life experiences which could be perceived as negative side effects. Emotions or physical discomfort may continue to arise after a session and you are encouraged to discuss such emotions or physical discomfort with me and, if appropriate, I can refer you to a licensed health care professional for further assistance.
Other Important Information
My work with you as an intuitive counselor/adviser and energy balancing practitioner is not intended to be used to diagnose, treat, cure, or prevent any disease or psychological disorder; our sessions together do not replace the advice and/or services of health care professionals. You agree to consult with your health care provider for any specific health care problems and understand that I may suggest you contact your professional health care provider if I believe it’s advisable. In addition, you understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing any of your health care professionals or using prescribed medication, if any, without consulting with your health care professional, even if after a session it appears and indicates that such medication or treatment is unnecessary. You agree to take full responsibility for your self-care in the, emotional, mental, physical, and spiritual dimensions of your life. You agree to contact me directly if you have any concerns about your experiences with your energy sessions and/or our relationship as practitioner and client.
Education and Training
I earned a Masters of Intuition Medicine (MIM) certificate, a three-year program in Intuition Medicine®, from the Academy of Intuition Medicine® and studied Sound Healing with Tom Kenyon under the auspices of Acoustic Brain Research [ABR], completed the Flower Essence Society Professional Course and I am a certified Relax and Renew Trainer® in Restorative Yoga.
Acknowledgment and Consent to Receive Services
By signing this document, you agree that I have disclosed to you sufficient information to enable you to decide whether or not to engage my services. You understand that you are freely choosing to take advantage of my intuitive counseling and energy balancing services and would otherwise have the option of using another practitioner of your choosing. You understand that your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. Further you understand the extent of Energy Medicine’s effectiveness as well as its risks and benefits are not fully known and you agree to assume and accept full responsibility for any and all risks associated with using Energy Medicine. You represent that you’re competent and able to understand the nature and consequences of our proposed sessions.
You have read and understand the above disclosure about the services offered by me and my training and education. You have discussed with me the nature of the services to be provided and you understand my services as an intuitive counselor and energy balancing practitioner are not licensed by the State of California. You agree to be personally responsible for the fees related to the services provided to me. By signing in the space provided below, you knowingly, voluntarily, and intelligently assume these risks and agree to release, indemnify, hold harmless and defend Mary Spicer and her agents, consultants, and employees from and against any and all claims of whatsoever kind or nature, which you, or your representatives, may have for any loss, damage, or injury arising out of or in connection with your sessions.
In order to use my services, California state law requires that you acknowledge receipt of the information provided in this Client Informed Consent and Disclosure Statement. I will keep an original in my records for at least three (3) years.
______________________________________________ __________________
Signature Date
© 2010 Midge Murphy. All rights reserved. Any unauthorized use of this Informed Consent is prohibited by federal law. No part of this document may be reproduced in any form or by any means, including photocopying, without permission in writing from Midge Murphy.
CLIENT INFORMATION SHEET [ Legal Information about Complimentary Medicine in California ]
In September 2003, California passed ground breaking legislation (California Senate Bill SB-577) which has profound implications for the practice of complementary and alternative forms of health care in California. SB-577 legally enables complementary and alternative health care practitioners to provide and advertise their services to California citizens. However, they must comply with certain requirements specified within the bill which has now become part of California law under sections 2053.5 and 2053.6 of California’s Business and Professions Code.
Sections 2053.5 and 2053.6 of California’s Business and Professions Code provide the following:
A. Provide access to complementary and alternative health care practitioners. You must be given information about the nature of treatment and the practitioner’s qualifications. Please ask your practitioner any question you may have about the treatment options they offer. Ask if you practitioner has been certified by a professional organization and if they belong to any professional organizations. Please tell your physician if you are receiving any alternative treatments. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet your health goals.
B. Requires unlicensed complementary and alternative health care providers to follow certain guidelines and to refrain from certain practices
C. Specifies that unlicensed complementary and alternative health care practitioners are NOT allowed to do:
Perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
Use X-ray radiation
Prescribe prescription drugs, or recommending that you discontinue drugs that were prescribed by a licensed physician.
Set fractures
Treat wounds with electrotherapy
Put you at risk of great bodily harm, serious physical or mental illness, or death
Imply in any way that he/she is a licensed physician.
D. Specifies that complementary and alternative health care practitioners MUST DO the following things:
- Provide you with a statement, written in plain language that includes the following information: (1) that they are not a licensed physician and that their services are not license by the state; (2) a brief and clear description of the kind of services they provide and the reasoning behind it; and (3) a description of their education, training, and experience.
- Ask you to sign and acknowledge that you received the above written statement, and provide you with a copy of it. They must also keep a copy of your signed acknowledgment for three years.
© 2010 Mary Spicer all rights reserved. Any unauthorized use of this publication is prohibited by federal law. No part of this website may be reproduced or transmitted in any form or by any means, including photocopying, without permission in writing from Mary Spicer.
