“Trauma need not be a life sentence. Of all the maladies that attack the human
organism, trauma may ultimately be one that is recognized as beneficial. I say this because in the healing of trauma, a transformation takes place – one that can improve the quality of life.”

-- Peter Levine

Agreement Form for Somatic Experiencing

I appreciate you asking me to help you. This informed consent and intake form is designed to give you information about my practice and our professional relationship and for me to learn more about you so that I may serve you in the best possible way.

The Scope of My Practice

The techniques used by Darla Bruno in private sessions are to facilitate personal growth and trauma resolution, provide stress-management tools, increase regulation and a sense of well-being.

I am an integrative wellness coach and Somatic Experiencing Practitioner (SEP), and Transforming Touch (TEB) Therapist, but not a psychologist, mental health counselor or LCSW. I do not diagnose, prescribe, or treat any physical or mental ailments.

I use my SE training and tools, along with stress-reduction techniques and mind-body interventions, as compliments to regular medical and psychological care. Which model and modalities/interventions I employ will depend on your situation and will be done with your informed consent.

I (Darla Bruno) can only work within the scope of my practice. If at any point in our work together it is determined that you (the client) would be better served by a different modality or provider, then you (the client) are free to seek consultation elsewhere and/or appropriate referrals will be made.

OTHER TERMS

 

Confidentiality

All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.

I regard the information you share with me with the greatest respect. I will maintain confidentiality and privacy of our work and my records as it is a privilege of yours and is protected by state law and professional ethics in all but a few situations. Under the mental health procedure act and professional ethics guidelines there are certain circumstances in which your consent for release of information will not be required. These include:

• Duty to warn about intent to harm others
• Danger to self
• Suspected child abuse, dependent adult abuse

 

Online Meetings

Recordings 

Please do not record Zoom sessions without my (Darla Bruno's) consent. 

 

Litigation Limitation

It is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc..), neither you nor your attorney’s, nor anyone else acting on your behalf may request that I (Darla Bruno) testify in court or at any other proceeding, nor may any of my records be requested unless otherwise agreed upon.

 

Disability 

I (Darla Bruno) cannot provide assistance with disability applications.

 

Consent to Share Case Information

Consent must be given for me to discuss your case with any other medical health professionals including, but not limited to other mental health providers, psychiatrist, psychologist.

 

Consultation

I (Darla Bruno) will occasionally consult with other professionals regarding my clients; however, my client’s identity remains completely anonymous, and confidentiality is fully maintained. I also always request permission from my clients prior to any consultation.

 

Fees

All fees are due at time of service unless other arrangements have been made between myself (Darla Bruno) and the client. I do not participate in any insurance plans or submit for out of network coverage.  

 

Cancellation

If you must cancel or reschedule a session, please give 24-48 hours notice outside of emergencies.

If sessions are consistently canceled or rescheduled, I will be unable to hold our regular meeting time and we may discuss alternate arrangements that may better meet your needs. 

Sessions are 60 minutes (per our discussion) and will start and end on time. Please have your child arrive a few minutes before session if possible.

If you arrive late, the appointment will still end at the agreed-upon time.

Emergency Services

Darla Bruno does not provide any emergency services. All phone messages and emails will be checked daily unless otherwise stated, but are not for use in an emergency, and responses may take up to 24 hours. In an emergency, please call 911 or report to your local emergency room.

 

Termination of Our Work

You have the right to refuse or terminate our sessions at any time, or to refuse SE touch, TEB, SE techniques, or any other intervention I may propose or employ. You always have the right to seek a second opinion or additional wellbeing services (such as EMDR, biofeedback, cranial sacral therapy, and other modalities that can work in accompaniment to SE). And I am happy to make such referrals.

If you need to pause, I may have others who are waiting for a slot in my practice. Discussion with regard to putting sessions on hold will simply allow me to best meet your needs.

If you have any questions about SE, at any point, or any of the work we engage in during our sessions,  please ask.