Complete Intake and Patient Agreement with Consent

Client Intake

Hello! Our intake takes a little time. We have one shared intake form, which means you only fill out one form for all of our practitioners. Thank you for taking the time to tell us about yourself. Please read the following statements, and fill out our intake. Please let us know if you have any questions. Call / Text (401) 300-5010
Preferred Name
Preferred Pronoun
Full Legal Name*
Email*
example@example.com
Phone Number *
Date of birth (you must be 18 years of age) *

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact *
Emergency Contact Phone Number*
Please enter a valid phone number.
Sick Policy
This office does not accept sick visits. We ask that if you have any symptoms of any contagious illness that you stay at home. This includes but is not limited to new cough, cold, fever, chills, new difficulty smelling, new difficulty tasting, new diarrhea, contact with anyone sick, contact with anyone COVID positive or quarantined. Addiitonally, anyone with athletes foot cannot participate in massage or foot reflexology.

*notify us right away with any changes

Click here for our COVID precautions https://holisticri.com/covid-precautions/
*

I agree to the sick policy

♦️Please Read Carefully: This section will guide to to the appropriate waiver for your visit
Please select all therapies that you may participate in the future. This will direct you to the appropriate waiver / form.*

Virtual or Telehealth visitsHerbalist ConsultsHealth Coaching (please also fill out membership agreement afterwards)Functional Medicine (please also fill out membership agreement afterwards) At this time for Functional Medicine we are only able to accept Rhode Island patients between the ages of 18-60.Reflexology or MassageJourneying, Transformational Coaching, and Integrative Energy MedicineReiki

General Notices, Rights, and Waivers
Holistic, adjunct therapies and health coaching should not replace or interfere with the care of a medical provider. Health Coaches, Reflexologists, counselors, herbalists and holistic practitioners are not medical providers. I understand that it is my responsibility to consult my PCP prior to making any changes. The holistic practitioner will not diagnose conditions or prescribe medications. By clicking agree, I give my consent to a holistic wellness session. I understand what it entails, as well as the cost of each session.*

I agree
Privacy
Holistic RI Practitioner Permission - I give permission for Holistic RI practitioners and providers to review this intake and share clinical findings. Only HRI practitioners providing direct therapies or consulting will access this information. We take your privacy very seriously. We do not share any personal information with any third parties without prior written authorization.*

I agree
Appointments Cancellations

We request a minimum of 2 business days notice for full refund, so that we are able to fill your spot and call those on the waitlist. Early cancellations are subject to cancellation fee up to full fee of service. No show will result in full payment.
General Notice

If you sign up for a membership: 60 day written notice required to cancel any membership. Cancellation fees may apply. Cancellation fees may be waived if the contract commitment has been met. Memberships are nontransferable, and nonrefundable. Failed payments subject to fee of $50.
General Terms of Use

For terms of use: https://holisticri.com/terms-of-use/
Signature*

Clear

Your HIPAA rights
Please review your HIPAA rights

Copy and paste this link into a browser if you are unable to view the PDF below https://holisticri.files.wordpress.com/2020/11/npp_fullpage_hc_provider.pdf
*

I have read my HIPAA rights
Today's Date*

MonthDayYear
Please Type Your Full Name *
Signature*

Clear

Reflexology and Manual Therapies
Reflexology, Massage, and Manual Therapies: I am medically cleared to receive this therapy. I do not have any blood clots, or athlete's foot. I will notify my therapist of any changes. - Manual therapies occasionally use heated stones, and heated towels. Please let us know immediately if anything is uncomfortable, too hot or too cold.*

I Agree
Reflexology, Massage, and Manual Therapies CANCELLATIONS: Any cancellations made with less than 24 hours notice will be charged a fee. First late cancellation is $35. Second cancellation is the full price of the therapy. NO SHOW POLICY: Any no-shows will result in a full fee charge. Please call us to avoid a no-show fee. (401) 300-5010*

I agree
Signature*

Clear

Health Coaching
Health Coaching and Herbal Consultations: I acknowledge that health coaches and herbalists are educators, and that they are not licensed providers. I understand the sole intention is to offer me the general educational information that I request. If I choose to use this information to work on myself, then I affirm that the responsibility is solely mine. I understand I should never use the information in any way that contradicts, conflicts, or opposes a course of treatment recommended by a primary care provider. If I ever perceive or feel that information given by the coach opposes a licensed provider's treatment or recommendations, it is strongly advised to follow the advice and instructions of my licensed primary health care provider.*

I understand and Agree
HEALTH COACHING: MEMBERSHIP - Our Health Coaching is offered as a membership service. Our goal is to optimize health and wellness in a more proactive way. This takes time. Our membership requires a minimum of a six month commitment. Any patient that does not fulfill their 6 month commitment is subject to an early cancellation fee of $125. Any patient that cancels their membership will have to re-join and is subject to a joiners fee. All patients are permitted to pause their membership for up to 3 months per year without a fee. A 45 day notice is required to pause a membership.

I understand and Agree
I am authorizing Holistic RI to charge my credit card on file in the amount of blanks dollars on a monthly basis. I am additionally authorizing my credit card on file to be automatically charged for any outstanding amounts, fees incurred, or cancellation charges.
Signature*

Clear

Depth Hypnosis, Transformational Coaching & Integrative Energy Medicine
Depth Hypnosis Waiver: Hypnotherapy is a self- regulated, not state-licensed, profession. We are a certified profession, and meet the highest standards set forth by the Association of Depth Hypnosis Practitioners and the Foundation of the Sacred Stream. We practice according to our organization's Code of Ethics and Standards. We have received high quality training through Depth Hypnosis Training Program and the Foundation of the Sacred Stream. We do not do medical diagnosis; nor are we licensed physicians or medical practitioners. We are certified healing arts practitioners - Certified Hypnotherapists. We provide hypnotherapy services, which give high-quality alternatives for people seeking to overcome many of the challenges of life. We pledge confidentiality. Recent research has found that memories uncovered during hypnosis, or other forms of induced altered states may not be accurate or even factual. Memory is a constructive and reconstructive process. What is remembered about an event is shaped by what was observed, by conditions prevailing during attempts to remember, and by events occurring between observation and attempted remembering. Memories can be altered, deleted, and created by events that occur during and after the time of encoding, during the period of storage, and during attempts at retrieval. Therefore, if memories should surface that may be considered grounds for future litigation during the course of hypnotherapy, you may lose your legal right to use this information in a court of law, as it may not be admissible. If certain types of memories begin to surface during any hypnosis session, the session will be discussed so that you may decide whether or not to proceed further with the hypnosis based on your understanding and careful consideration of the above information. Depth Hypnosis can bring up strong emotions and by signing this document you are indicating that you feel stable enough to handle those emotions. The Hypnotherapist is not liable for any pain or emotional distress that may ensue in the course of this work, and it is understood that you will seek medical or psychiatric help as the need arises.*

I understand and agree
Signature*

Clear
Integrated Transformational Coaching Disclaimer and Waiver: Coaching is a service that provides personal coaching to specific individuals and/or groups. The client is aware that coaching is in no way to be construed or substituted as psychological counseling or any other type of therapy or medical advice. I understand and acknowledge that the Coach and Holistic RI will not be liable legally or otherwise, for the actions I may or may not undertake as a result of the coaching sessions.I agree that using any of the coaching services is entirely at my own risk. Coaching services are provided “as is” without warranty of any kind, either expressed or implied, including without limitation any warranty for information services, coaching, uninterrupted access, or products and services provided through or in connection with the service. This service is requested at the client’s own choice and with inherent singular responsibility. Any actions or lack of actions taken by the client is done solely by choice and responsibility of the client and is neither the responsibility nor liability of the Coach or Holistic RI. The client takes full responsibility in the decisions they make after being coached as well as the consequences. The client enters into coaching with full understanding that they are responsible for creating their own results.I hereby release, waive, acquit and forever discharge my Coach, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation, for damages I may claim to have or that I may have arising out of acts of omissions by myself or by my Coach as a result of the advice given by my Coach or otherwise resulting from the coaching relationship.*

I agree
Signature*

Clear

Telehealth
Telehealth Consent - 1. I hereby authorize Health Care Services to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition. 2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended. 3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met. 4. I understand that my current insurance may not cover the fees of the telehealth practices and that I am responsible for all fees incurred. 5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.*

I understand and agree to all of the above
Patient Information and Patient Responsibilities: The Patient Portal and secure apps allow you to communicate with the Practice via secure messaging. Please note that all communication via the Patient Portal will be included in your permanent patient record. Electronic communications will be viewed by not only the provider, but the staff members assigned to handle such communications and any other provider covering for the patient’s provider if the patient’s provider is unavailable to respond.Please note that online communications should never be used for emergency communications or urgent requests. Follow-up is solely your responsibility. You are responsible for scheduling any necessary appointments and for determining if an online communication did not receive a response.You are responsible for taking steps to protect yourself from unauthorized use of online communications, such as keeping your password confidential. The Practice is not responsible for breaches of confidentiality caused by you or an independent third-partyThe Practice may stop providing online communications with you or change the services provided online at any time without prior notification to you. Ways to keep your data safe: The Patient Portal and secure apps allow you to communicate with the Practice via secure messaging. Please note that all communication via the Patient Portal will be included in your permanent patient record. Electronic communications will be viewed by not only the provider, but the staff members assigned to handle such communications and any other provider covering for the patient’s provider if the patient’s provider is unavailable to respond.Please note that online communications should never be used for emergency communications or urgent requests. Follow-up is solely your responsibility. You are responsible for scheduling any necessary appointments and for determining if an online communication did not receive a response.You are responsible for taking steps to protect yourself from unauthorized use of online communications, such as keeping your password confidential. The Practice is not responsible for breaches of confidentiality caused by you or an independent third-partyThe Practice may stop providing online communications with you or change the services provided online at any time without prior notification to you.*

I understand and agree
HRI - Electronic Communications and Virtual Appointment Portal: "The practice" refers to Holistic RI (HRI), and HRI independent contractors including but not limited to all practitioners and affiliates. The Practice uses reasonable efforts to maintain the Patient Portal, but the Practice is not responsible for any defects or failures associated with the Patient Portal, any part thereof or any damages (such as lost profits or other consequential damages) that may result from any such defects or failures. The Patient Portal may be inaccessible or inoperable for any reason, including, without limitation: (a) equipment malfunctions, (b) periodic maintenance procedures or repairs which the Practice may undertake from time to time or (c) causes beyond the control of the Practice or which are not foreseeable by the Practice. In addition, the Practice makes no guarantees as to the web sites and information located worldwide throughout the Internet that you may access as a result of your use of the Patient Portal, including as to the accuracy, content, or quality of any such sites and information or the privacy practices of any such site. The Practice is not a backup service for storing data you submit to the Patient Portal, and the Practice shall have no liability regarding any loss of such data. You are solely responsible for creating backups of any data you submit using the Patient Portal.The Patient Portal is a secure website that allows you to use a computer to interact with medical information via the internet. The Patient Portal also allows you to communicate with the Practice via secure messaging. Please note that all communication via the Patient Portal will be included in your permanent patient record. If the portal is malfunctioning, an alternative video chat, or phone chat may be utilized in its place.*

I understand and agree
Emergencies: Please note that online communications should never be used for emergency communications or urgent requests. If you are experiencing an emergency you must call 911.*

I agree
I understand the risks associated with online communications between me and my provider's office. I consent to the conditions outlined and I agree to keep my password confidential and notify the office if my email address changes at any time. All of my questions have been answered and I understand and concur with the information*

I agree
Messaging: App Messaging, email, or other means of communication are not to be used for urgent or emergent needs. If you are experiencing an emergency, you must call 911. We are available M-F EST during business hours. Please allow at least 48 business hours for us to formulate a thoughtful reply. MESSAGES ARE NOT FOR URGENT NEEDS. MASSAGING IS TO BE USED AS A SUPPLEMENT TO CLARIFY AND ASSIST BETWEEN APPOINTMENTS.*

I agree
Signature for Telehealth Consent *

Clear

JOIN OUR EMAIL NEWSLETTER: Optional

Please enter your email here only if you would like to be added to our emailing list
Preferred Name
Email
example@example.com

Submit

Please submit the form by clicking the button below
Should be Empty:

Client Intake

Sick Policy

Getting to know you

Safety and History

♦️Please Read Carefully: This section will guide to to the appropriate waiver for your visit

General Notices, Rights, and Waivers

Privacy

Appointments Cancellations

General Notice

General Terms of Use

Your HIPAA rights

Reflexology and Manual Therapies

Health Coaching

Depth Hypnosis, Transformational Coaching & Integrative Energy Medicine

Telehealth

Functional Medicine

JOIN OUR EMAIL NEWSLETTER: Optional

Submit