CONSENT & DISCLOSURE FORMS

 

D E L P H I N E ~ L I P P E N S , SEP +

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Metaphysical & Intuitive Bodyworker
Somatic Experiencing + Touch Practitioner

Body-Mind Practitioner

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General Informed Consent

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Name (please PRINT)

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Address (optional)
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Phone #: Home

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Phone #: Cell

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E-mail (optional)

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Birth date (optional)

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Referred by

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Physician

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Emergency contact: (name - relation - phone # )

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What your intention for these sessions?

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As of January 2003, Alternative and Holistic Health/Healing Practitioners, such as myself, Delphine Lippens, can lawfully practice in the State of California without violating the state’s Medical Practitioner Code, under section 2053.5 and 2053.6 of California’s Business and Professional Code. I am allowed to offer Aromatherapy, Raindrop Technique, Spiritual Touch, Assisted Meditation, Sensory Repatterning, Intuitive Cranial Sacral Unwinding, Intuitive Healing, Somatic Trauma Resolution / Release, Somatic Experiencing and other holistic health services as long as I make the following disclosure and obtain from you a written acknowledgment and consent to receive services (and I retain a copy for at least three years).

Disclosure

I, Delphine Lippens, am not a licensed physician and I am not allowed to perform surgery, puncture your skin, use x-ray radiation, prescribe drugs, or recommend that you discontinue drugs that were prescribed to you by a licensed Physician. I am not allowed to set fractures or put you at risk of great bodily harm, serious physical or mental illness, or death. I am not allowed to imply that I am a licensed physician. The services I provide are not licensed by the state of California. The treatments that I offer are alternative and complement other healing arts services licensed by the State of California.

My Qualifications are: Certificates, CEU forms and Transcripts available upon request.

Tardiness & Cancellation Policy

Please allow a 24-hour courtesy notice for cancellation or payment will be expected for the scheduled time. If you are running late, understand that the session will end on the originally scheduled time. If you miss an appointment (by phone or in person) more than once, you will be liable to pay for the session.

Delphine Lippens accepts the right to refuse service or end a session at anytime and/or the relationship if the client’s behavior becomes inappropriate.

Acknowledgment & Consent to Receive Services

Because certain essential oils, movements and other bodywork may be contraindicated in certain medical conditions, I agree to keep the practitioner updated as to any changes in my physical, emotional and medical profile and understand that there shall be no liability on the practitioner should I forget to do so. I understand that the work I am here to receive is for the basic purpose of relaxation and is an alternative and complement to other healing arts services licensed by the State of California. If I experience any pain or discomfort during a session, I will immediately inform the practitioner so that any issues may be addressed in the moment. I further agree that the work we do together, physical, esoteric, energetic, spiritual and so forth should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a qualified medical specialist for any ailment I am aware of. No words exchanged before, during and after a session should be construed as a diagnosis, or shall be taken as such.

I (print name)______________________________________________ have read and understand the above disclosure. By signing this document, I consent to use the services offered by Delphine Lippens and agree to the above-mentioned policies, give my consent and authorization voluntarily and release Delphine Lippens of any claims that I have or may have in the future, in connection with the received treatment(s) and to be personally responsible for Delphine Lippens’s fees.

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Client Signature

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Date

You are welcome to receive a copy for your own records.

I BELIEVE I CAN HEAL

I DESERVE TO HEAL

I CHOOSE TO HEAL

I AM WORTH IT

"... and notice your breath ..."

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D E L P H I N E ~ L I P P E N S , SEP +
______________________________________

Metaphysical & Intuitive Bodyworker
Somatic Experiencing® + Touch Practitioner

Body-Mind Practitioner

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Somatic Trauma Resolution / Somatic Experiencing®
Informed Consent

SE is a short-term naturalistic approach to the resolution and healing of trauma (developed by Dr. Peter Levine) and is supported by research. It is based upon the observation that wild prey animals, though threatened routinely, are rarely traumatized. Animals in the wild utilize innate mechanisms to regulate and discharge the high levels of energy arousal associated with defensive survival behaviors. These mechanisms provide animals with a built-in “immunity’’ to trauma that enables them to return to normal in the aftermath of highly ‘’charged’’ life-threatening experiences.

* SE employs awareness of body sensation to help the person "renegotiate" and heal, rather than re-live or re-enact trauma.

* SE's guidance of the bodily "felt sense" allows the highly aroused survival energies to be safely experienced and gradually discharged.

* SE may employ touch in support of the renegotiation process.

* SE “titrates” experience (breaks down into small, incremental steps), rather than evoking catharsis - which can overwhelm the regulatory mechanisms of the organism.

SE can result in a number of benefits to you, such as relief of traumatic stress symptoms, increased resiliency, and resourcefulness. Like any other treatment, it may also have unintended negative side effects, such as sleep disturbances, frightening memories, or unfamiliar and uncomfortable body sensations. Such reactions are not uncommon and can be attended to in the course of our work together. It is important that you are aware that there are other forms of body-oriented and somatic psychotherapy modalities that may also be helpful to you, such as EMDR, Somatic Psychotherapy, Bodynamics and other body-mind modalities. There are also many non-somatic focused forms of psychotherapy and counseling that you can choose from alongside SE as SE is not counter indicated with any other types of healing work and only complements it.

It is your responsibility to tell me when you are uncomfortable with any parts of the treatment. If you have any questions about SE or other treatments, please ask and I will do my best to answer your questions in full. You have the right to refuse or terminate treatment at all times, or to refuse touch, SE techniques, or any other intervention I may propose or employ.

I have read the above informed consent, understand, and agree to it.
(Please let me know if you’d like a copy for your own records)

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Client name (print)

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Client Signature ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

For more information about SE please note the following references:
http://www.traumahealing.com
http://beyondtraumasymptoms.blogspot.com