Beyond the Veil Higher Healing Centre LLC
Intake Form Agreement
Consent to Treatment
You are about to take a very important step in your wellness. As your partner, Beyond the Veil Higher Healing Centre LLC and it's independent contractors will be entering into a protected relationship. Discussions and services will involve a multidimensional non-traditional approach. Due to this consent is needed for all those attending sessions. I am assisting you and I will do our best to accurately assist you and design a plan that will enable you to continue with development. This may include recommendations of other therapy. I will also work with your primary care physician, insurance or government bodies to assure coordination of care--if you so desire, and only with your signed permission.
You are my client and have confidentiality rights. Confidentiality does not apply under certain situation: Beyond the Veil Higher Healing Centre LLC and it's independent contractors are obligated by law to report any suspicion of child abuse. This includes physical or sexual abuse. Also, Beyond the Veil Higher Healing Centre LLC and it's independent contractors have a duty to protect if we suspect anyone is in danger of killing themselves or has made threats to hurt someone else. Except in these rare situations, your child has the right to keep particular topics confidential from even his/her guardian. Please respect this confidentiality. Again, if there is any concern of harm, suicide or other dangerous behavior, we will inform you. If Beyond the Veil Higher Healing Centre LLC and it's independent contractors require or think it is in your best interest to communicate with an outside source, we will request a release of information. To assure good care, frequent appointments are required. Unless arranged otherwise, clients that have not been seen in 3 months will be considered inactive. A new evaluation will be required for any inactive client to be seen. Beyond the Veil Higher Healing Centre LLC and it's independent contractors are considered as a non-traditional, alternative therapy providers. If we are not the right fit for your particular needs, we will provide you with a few referrals. I am aware that I may stop sessions with this professional at any time.
I, _______________________________(client), do hereby seek and consent to take part in the treatment provided by Beyond the Veil Higher Healing Centre LLC. If I am attending group services I also understand and consent that confidentiality still applies and that Beyond the Veil Higher Healing Centre LLC is not liable for group members breaking confidentiality. I understand that developing a plan with this provider and regularly reviewing our work toward the treatment goals is in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this professional.
I am aware that if I attempt to contact my provider through phone, email, text, or any other form of communication over the Internet, my information may not be completely secure. In the event that my information is intercepted, Beyond the Veil Higher Healing Centre LLC is not responsible for the breach of patient privacy. No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.
Terms & Conditions
In consideration of being permitted to participate in any way in Beyond the Veil Higher Healing Centre LLC services, I, for myself, or my person representatives do hereby release, wave, discharge and covenant not to sue Beyond the Veil Higher Healing Centre LLC and it's independent contractors from any and all claims in personal injury, accidents or illness (including death), and property loss arising from, but not limited to, participation in Beyond the Veil Higher Healing Centre LLC and it's independent contractors.
I also agree to indemnify and hold Beyond the Veil Higher Healing Centre LLC offers, employees, volunteers and agents harmless from any all claims, actions, suits, procedures, costs, expenses, damages, liabilities, including attorney’s fees brought as a result of my involvement in Beyond the Veil Higher Healing Centre LLC. and to reimburse of any such expense incurred.
The undersigned further expressly agress that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Texas that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
I represent I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.
Appointments canceled within 24 hours or for which clients are a “No-Show” for will incur a charge of 30% of the service amount to the credit card on file.