CLIENT INTAKE FORM

Family Heredity Main Family Illnesses

Please take a moment to carefully read the following information, and sign where indicated. As a Natural Health Consultant, Brennan Healing Science Practitioner, Indigenous Practitioner, Conflict Resolution Facilitator and Peacemaker Minister, I do not medically diagnose or prescribe treatment. My approach is holistic, focusing on you as a complex, dynamic, unique being-body, mind, and spirit and I serve as a facilitator in your process of healing. I have had a private practice since 1994.

We may explore areas that influence your state of well-being, such as your health history, life stressors, your belief systems and attitudes, your family and childhood history, diet, exercise, and how you are in relationship. Your sharing is always kept confidential. I do, however, discuss clients with my professional supervisor or professional peers for the purpose of my continuing professional development.

The hands-on-healing techniques balance, clear, and charge your energy field and system, remove energetic blocks that lead to disease, and enhance your body's natural healing potential. At times I will touch your body, and at other times I may work with your energy field off your body. If at any time during the session you are uncomfortable, it is your responsibility to inform me. Self-care is an extremely important part of your healing process.

I prefer to set up a regular schedule to work with you although there is never an obligation to continue treatment. I do request 24 hours notice of cancellation in advance; otherwise, my policy is to charge you the full session fee. The exception is emergencies and illness. The fee for the first session is $165.00 (duration one hour and a half Other scheduled sessions are at a fee of $110.00 (duration one hour and may be up to one hour and fifteen minutes), payable by check, money order or cash at time of session.

Due to the nature of this work, I recommend that you refrain from using alcoholic beverages for 24 hours following your session. I am most happy to answer any questions regarding my services, and I also encourage you to express any concerns. I look forward to working with

I have read and understand the above information provided by Rosa Bergola.

Ifurther understand that her services are not to be construed as medical examination, diagnosis, or a substitute for medical treatment, and that nothing said or done during the course of the session or sessions given should be construed as such.

The client confirms that s/he has presented themselves in their own name, in good faith and for no other reason than to obtain a natural therapy treatment.

National Association of Naturopaths

The client has read and understood the following The receipt issued by the therapist is given as an acknowledgement for the sum of money received by the client for services rendered. The use of this receipt is for no other purpose other than for the reimbursement of monies by your insurance company and it is the exclusive responsibility of the client to file for reimbursement. The therapist is not involved in any way with the admissibility or non admissibility of this receipt.

The client acknowledges that s/he has presented themselves under his real name, in goodwill and for no other purpose than to receive a natural therapy session.

PROVISIONS RELATED TO THE ACT RESPECTING THE PROTECTION OF PERSONAL

You have given us information regarding your private file. Following the adoption of Bill 68, and unless otherwise instructed by yourself, we shall consider that you consent to our keeping in a file, all information you have already given or may give us, orally or in writing. We shall also consider, unless otherwise instructed by yourself by registered mail, that your consent will be valid for a period of five (5) years.

I hereby consent freely to the fact, that

Will gather in a file from now on, all the information that I will transmit whether it be written, oral or computerized.