Intake form for sessions by Skype or Phone
Please fill out the following form in its entirety and submit it to me a minimum of 48-hours prior to your scheduled session.
[contact-form 2 “Intake Form for Session by Skype or Phone”]
By submitting this form, I signify that I have read, understood and agree to the following:
The principles of Ortho-Bionomy provide the structure for our work together. Ortho-Bionomy is a gentle approach for re-discovering ease and comfort within oneself that is most effective through the active engagement of the client. It is very important to let me know immediately if you experience any discomfort and to ask any questions as they arise. Your input is important as we work together to explore your particular concerns. Your engagement and questions are welcome and expected.
POLICIES AND CONSENT FOR CARE
Confidentiality: All information disclosed within sessions and the written records of those sessions are confidential and may not be revealed to anyone without your written permission, except where required by law.
I, the person submitting the form above, am requesting a healing session with Larisa Noonan session for the purpose of enhancing the wellbeing of my body and mind. I understand that this therapy is not intended as diagnosis, prescription, or treatment of any disease, physical or mental. I also understand that this therapy is not intended as a substitute for regular medical or psychiatric care and that I’m not being advised by Larisa Noonan to discontinue any prescribed medication or medical/psychological care.
- I understand that either party may choose to terminate the relationship at any time for any reason.
- I understand that I am personally responsible for payment and that the fees are due and payable prior to the time of service.
- I also understand that for future appointments a 24 hour cancellation notice is required. If I do not provide 48 hours notice by calling 503-975-3300, I will be responsible for the full session rate ($200).
Through submitting the above form, I signify that I understand that in the course of working with the patterns involved in my particular issue, deep emotional patterns may come up as well. If I am ever feeling upset or angry with Larisa or if I feel my wellbeing is being compromised in any way, I will communicate it to you as quickly as possible.
I commit to having an open, honest communication with Larisa so that we may address whatever the issue may be in the most compassionate and healthy way possible so that we both may feel clear and understood and move forward on good terms with one another.
I understand that Larisa Noonan will hold herself to the same standard of communication and respect.
I agree to give 48-hour notice of cancellation if I am unable to attend a session. In the event that I am unable to give 48-hour notice of cancellation, I will notify Larisa with as much advance notice as possible. I agree to pay the full price of the session ($200) if I do not give 48-hour notice. Exceptions may be made for emergencies or abrupt illness.
Lastly, I agree to grant Larisa the right to cancel with less than 48-hour notice in the case of a personal emergency or illness. In this case, she will notify me with as much advance notice as possible by, if necessary, both phone and email. Further, she will make every attempt to reschedule my session at our earliest convenience.
Personal note from Larisa
Thank you for taking the time to fill out and submit the form above and to read through and agree to my policies and agreements. I am so looking forward to working together with you.