Agreement Regarding Consultation/Sessions
THE CLIENT AGREES To:
Be on time (for in person sessions and phone sessions)
To give at least 48 hours’ notice: To email the office at: firstname.lastname@example.org at least 48 hours in advance in case the scheduled appointment needs to be canceled or rescheduled.
Of any appointment(s) missed, cancelled, rescheduled without 48 hours notice. These will be lost, without reimbursement.
Not a licensed mental health provider and does not render psychiatric services.
I/the client am aware that Dr. Alice Williams is not establishing a doctor patient relationship with me and is not taking on the role of a medical practitioner/provider. I am aware that in the Consultation(s)/Sessions(s) I will not receive medical diagnoses, treatment or prescription. The Consultation(s)/Sessions(s) provided are not licensed by the state. For legal reasons, no medical claim is made as to the efficacy of these sessions.
Not a Substitute for Licensed Health or Medical Care
These services are not a substitute for licensed health or medical care. For medical diagnoses and treatment of disease, I am aware that I need to consult with a licensed health and/or medical practitioner. I understand that Consultation(s)/Session(s) with Dr. Alice Williams are not intended to replace these. I am aware that any advise or suggestions I am given I will need to discuss with a licensed health and/or medical practitioner before implementing.
Agreement to Continue Licensed Treatment
I agree to continue any licensed health or medical treatment that I/the Client may be receiving while I am concurrently consulting with Dr. Alice Williams.
Fees may increase at any time. Fees are due in full in advance of each session or Package. When a Package of sessions has been pre-purchased, the number of sessions will be subtracted from the Client’s package at the end of each session and the Client’s new balance of sessions will be calculated. Client may request an official balance of sessions at any time. Any fees paid in advance for sessions that are missed, canceled or rescheduled without 48 hour notice, or not met 15 minutes after scheduled time, will be forfeited without reimbursement. All services are non-refundable.
In Consultation(s)/Session(s) Dr. Alice Williams may use (but not limited to) Medical Intuition, Energy Healing and Nutrition.
I/the client am acting solely on my own behalf. I do not represent any other person, entity and/or governmental agency.
PERMISSION AND AUTHORIZATION, and RELEASE
Permission and Authorization
I permit and hereby authorize Dr. Alice Williams to provide the above series, and to inform and educate me about natural, complementary health-supporting options in order that I may develop my own appropriate health-supporting program(s) at home, and not for the treatment or cure of any disease. This permission form applies to this, and all subsequent Consultation(s)/Session(s)
I/the client hereby acknowledge that I have read all of the foregoing sections, that I am satisfied that I fully understand the nature of the Consultation(s)/Session(s), and that I freely elect to receive the same. I release and discharge Dr. Alice Williams from any and all claims of malpractice, non-disclosure, or lack of informed consent: damages, demands, or actions whatsoever in any manner arising from or growing out of my participation in these sessions. I freely assume any risks of the Consultation(s) whether presently contemplated or later discovered. I agree to hold Dr. Alice Williams harmless for any claims or damages in association with our work together. This is a contract between Dr. Alice Williams and myself, the Client, and is a general release of liability for Dr. Alice Williams/Expanding Healing.
By making an appointment and payment, I/the Client indicate my understanding of and agreement to the terms and conditions of the entire above stated Agreement.