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

Intake, Agreements and Consent for Biodynamic Craniosacral Therapy (BCST)

This form was designed to help me understand more about you, your goals and what contributes to your well-being. The more you answer, the better equipped I am to serve you, but I recognize that not every question may be easy to answer. If you don’t feel comfortable answering something here, you can skip it and we can talk about it during your visit.

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:

How did you hear about me?

Internet Search

Facebook

Instagram

Referral

If "Referral", who referred you?

Health and Wellness

Please describe the reason you are seeking treatment today including when and how it began.

Please describe the nature of this concern. What aggravates it? What relieves it?

Please rate the discomfort of this concern on a scale from 0-10, with 10 being the most uncomfortable.

Have you sought treatment for it before? If so, how did you feel about these previous treatments? Where were they successful?

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

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

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 an illness, disease, or physical condition? Please describe:

Please rate your current energy levels on a scale from 0-10, with 10 being the most energetic.

How much sleep do you get and what is the quality of that sleep?

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?

Have you had any surgeries? For what and approximately when?

Please select all psychological concerns that apply.

Please select all circulatory concerns that apply.

Please select all systemic concerns that apply.

Please select all head and neck concerns that apply.

Please select all skeletal concerns that apply.

Please select all neurological concerns that apply.

Please select all respiratory concerns that apply.

Please select all digestive concerns that apply.

Please select all skin concerns that apply.

If you are dealing with a concern that was not listed above, and you believe that it is important for me to know about it, please include it here:

Please rate your current level of stress on a scale from 0-10, with 10 being the most stressed.

Where in your body do you hold tension?

What do you do to relax and have fun? How do you like to resource yourself?

Have you ever experienced trauma? (You are not required to disclose this. It is absolutely optional. I inquire simply so that I can offer you choice, empowerment, collaboration and safety within our therapeutic relationship.)

Goals and Special Requests

Have you had previous experience with biodynamic craniosacral therapy (BCST)? If so, please describe.

Benefits of BCST can include, but are not limited to: relaxation, pain relief, better sleep, improved immune function, inner exploration, mental focus/meditation, mind/body awareness, emotional release, curiosity and increasing ability to receive healthy touch. What are your main goals for this session?

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

Your physical and emotional safety is of utmost importance to me. Would you like to request special accommodations to help you feel safe? If your answer is "Yes", please specify what accommodations you require. Examples could include, "I need a pillow under my knees when I lie on my back", "my feet are ticklish", "I overheat easily", "I am always cold and require extra blankets", or "I don't like the front of my neck being touched", or something else.

Is there anything else that would be useful for me to know to plan a safe and effective session for you?

Agreements
&
Consent for BCST

Roles

-I, the client, understand that my craniosacral therapist’s role is to provide manual therapy, as well as offer support, guidance and information within their scope of practice. -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 any healing process.

I agree and understand

Scope of Practice

-I understand that biodynamic craniosacral therapy is an experimental or alternative clinical approach that is still gaining acceptance within the conventional medical community. It is not yet considered evidence-based or the standard of care at this time. -I understand that my craniosacral therapist has received training in this field and has met the required standards for their professional certifying organization. -I understand that my craniosacral therapist 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 craniosacral therapist 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 is 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 craniosacral therapy services should be used only in conjunction with my obtaining that care. -I understand that while there may be some similarities, a biodynamic craniosacral therapy session is different from a massage. -I understand that a BCST session includes: intake, manual therapy and homecare instructions. -I understand that removal of clothing is unnecessary in a BCST session.

I agree and understand

Emergencies

-I understand that my craniosacral therapist 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. My craniosacral therapist will do their best to continue to provide services, as appropriate, if a crisis or emergency develops during our work together.

I agree and understand

Guarantees

-While my craniosacral therapist 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 for any particular issue or purpose. Any 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 agree and understand

Benefits and Risks

-I understand that the potential benefits of BCST can include, and are not limited to: nervous system relaxation and the associated resolution of conditions resulting from stress and trauma, including tissue healing, inflammation reduction, improved immune system function, and pain reduction. -I acknowledge that with any form of therapy there can be risks, and I assume those risks. I understand that during or after a BCST session, I might temporarily experience one/some/none of the following: fatigue, thirst, emotional releases, soreness/tenderness in familiar or new locations, lightheadedness/dizziness, symptom aggravation, temporary ”healing crisis” (physical reaction to the movement or release of energy in the body that is ultimately beneficial). -Other risks of craniosacral therapy include the transmission of Covid-19 and other transmissible infections. I agree to cancel my appointment if I am displaying any symptoms of cold or flu.

I agree and understand

Accuracy of Information/Disclosure

-I agree to disclose my medical history and any life conditions that may affect my sessions, including medications I may be taking for depression, anxiety or any psychological or psychiatric problem, in the New Client Intake Form. -If my medical condition should change, I will notify the craniosacral therapist BEFORE subsequent appointments and any life conditions that may affect my sessions, including medications I may be taking for depression, anxiety or any psychological or psychiatric problem, in the New Client Intake Form.

I agree and understand

Physical Contact

-Physical contact, even in a healing relationship, can be a sensitive matter because touch can be easily misinterpreted and feel too intimate or too uncomfortable in nature. I am aware that craniosacral therapy is a manual therapy that involves gentle, safe contacts or “holds”. My craniosacral therapist will always explain ahead of time when and where they will use physical contact, and I can let them know if I am comfortable with it or not. My craniosacral therapist will always honor any requests not to use physical contact. Touch can also 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 craniosacral therapist 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 craniosacral therapist know as soon as possible.

I agree and understand

Other aspects of my relationship with my craniosacral therapist

-I understand that I am my craniosacral therapist's CLIENT. My hypnotherapist 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 agree and understand

Record-Keeping

-I understand that my craniosacral therapist 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 craniosacral therapist make a copy of my file available to other health-care providers. My craniosacral therapist will maintain my records in a secure location that cannot be accessed by anyone else. My records will be retained for at least seven years after my last appointment, after which time my craniosacral therapist will securely dispose of them.

I agree and understand

Confidentiality - 1

I understand that my craniosacral therapist 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 behavior, 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 agree and understand

Confidentiality -2

Other possible situations of note involving confidentiality are: (1) If my craniosacral therapist 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 craniosacral therapist’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 craniosacral therapist 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 craniosacral therapsit needs to consult with other professionals about our work. During a consultation, my craniosacral therapist 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 craniosacral therapist will not tell me about these consultations unless they feel that it is important to our work together.

I agree and understand

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 agree and understand

Fee structure and payment

-I understand that a 60 min intake or follow up appointment is $120. -I understand that a 90 minute intake or 90 minute follow up appointment is $175. -I agree to meet my financial obligations promptly, including paying for any missed appointment without 24 hours notice.

I agree and understand

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 agree and understand

Contacting My Craniosacral Therapist

I understand that my craniosacral therapist is often with or preparing for work with a client, and is often not immediately available by telephone, text or email. 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 9 am and 5 pm, with the exception of weekends and holidays. I understand that my craniosacral therapist 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 agree and understand

Terminating Services

-Normally, I will be the one who decides when my work with my craniosacral therapist will end, but I understand that there are some exceptions to this. 1. I understand that the goal of our exchanges is to help me. If, during our work together, my craniosacral therapist feels that working together is not helpful enough to me, or discovers that I am not, in fact, someone who can benefit from craniosacral therapy, I understand that I will be notified immediately and our work together will be discontinued. 2. I understand that in some cases if the craniosacral therapist 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 craniosacral therapist, they reserve the right to discontinue our work together. 4. I understand that my craniosacral therapist 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 agree and understand

Complaints

-I understand that if I am unhappy with the way my work with my craniosacral therapist is proceeding, I can talk to my craniosacral therapist about it so that they can respond directly to my concerns. My craniosacral therapist will take such concerns seriously and meet them with care and respect. If I believe that my craniosacral therapist has been unwilling to listen and respond, or that they have behaved unethically, I can register a complaint about their behavior with the organization that certifies them as a clinical craniosacral therapist: The Biodynamic Craniosacral Therapy Association of North America, https://www.craniosacraltherapy.org/

I agree and understand

Please print your full name:

My signature below affirms that I understand and agree with the policies and procedures of Sea Change Wellness as well as provides my CONSENT FOR BCST. -I understand that consent is voluntary. -I understand that after signing this form, I confirm my consent to BCST and intend this consent to cover all subsequent BCST sessions as proposed by my therapist to deal with the problem for which I have sought assistance. -I understand that I can modify or withdraw my consent at any time. -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 BCST. *

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 for my child and intend this consent to cover all BCST sessions as proposed by the craniosacral therapist. I understand that at any time I may withdraw my consent and BCST 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 BCST.

Clear

*If you click on the "submit my information" button and nothing appears to happen, it means that one ore 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.