Informed Consent Form Logo
  • Informed Consent Form

    Holistic Family Occupational Therapy, LLC
  • Thank you for your interest in my services. It is important that you get to know and understand the salient points of holistic occupational therapy. Just like other types of interventions, there are benefits and risks involved. I shall explain it here in this informed consent and you can also ask if you have further questions or if you need clarification. I will also explain them to you before a intervention modality shall be done.  Please note that you have the right to decline any part of the intervention before or during intervention. You have the right to ask about the treatment plan and discuss the potential risks and benefits of the treatment.

  • What is Holistic Occupational Therapy?

    It combines the framework of traditional occupational therapy with alternative and integrative health techniques for a deeper level of development and recovery. 

    Treatment modalities include but not limited to:

    MNRI®, Masgutova Neurosensorimotor Reflex Integration, which involves non-invasive techniques that aim to restore genetic reflex programs in the brain to improve neurological circuits for natural development and recovery of fight/flight/freeze responses. 

    RMTi®, a movement based, primitive (infant or neo-natal) reflex integration program that uses developmental movements, gentle isometric pressure and self-awareness to rebuild the foundations necessary to help overcome learning, sensory, emotional and behavioural challenges for children and adults.

    Emotion Code®, which is an energy-based therapy modality that identifies and releases negative trapped emotions from the body from intense emotional experiences derived from self or inherited from family. 

    Holy Fire Reiki is a form of spiritual energy healing that builds upon traditional Usui Reiki practices but adds a component described as the “Holy Fire” energy — seen as a higher-level, more refined spiritual life force energy. 

  • How are interventions provided? 

    Interventions may be provided in person (client residence), virtually (zoom), or by proxy (distance).  Proxy method is for energy based intervention only.

    In person sessions are performed within client residence in preferred home space.   Infants and young children sessions are performed on mat and mature children and adults are perfromed on a massage table. 

    Virtual sessions are performed through private zoom meeting. 

    Proxy sessions are performed from a distance and client can be anywhere at the agreed upon date and time.  These sessions do not need to be done over telephone or computer.   This type of energy healing is based upon the principles of quantum physics, quantum entanglement and nonlocal reality. 

  • What are risks related to holistic occupational therapy? 

    Holistic occupational therapy intends to resolve the developmental, physical, or  energetic imbalance that is causing deficits or limitations in daily life.  Exercises performed should not inflict pain.  If pain exists prior to intervention this needs to be assessed by medical physician and then clearance would need to be given by treating medical physician before deficit can be addressed. The client is responsible to communicate if any exercises are painful or uncomfortable.  Muscle stiffness with exercises may cause discomfort, but not pain or sustained discomfort once therapy modalities are completed.  

    Emotion code, energy based therapy, may have processing related symptoms after emotions are released.  Processing related symptoms may include fatigue, moodiness, vivid dreams, and in some cases malaise. Processing symtoms are temporary and length depends on person.  Typical processing period is 1-8 days.  

     

  • What are expectations with holistic occupational therapy? 

    There are no guaranteed expectations that any or all deficits or limtiations will be resolved with intervention. Progress in therapy can vary depending on degree of deficit or limitation, physical or mental diagnosis, and participation with home program.  Sometimes referrals to other alternative or medical professionals are recommended. It is important that the client is truthful with what he or she thinks or feels.  Proper communication is critical for best outcomes.  

  • About the Therapist:

    I have more than 20 years of experience in various settings primarily with pediatric population.  My passion is neuroreflex integration and traumatic/chronic stress recovery. 

    My mission is to help children reach their full developmental potential as well as assist adolescents and adults in recovery of traumatic or chronic stress. 

    In addition to being a holistic occupational therapist, I am a mother of two very special boys. My boys were my BEST teachers. I realized very quickly that you don't truly understand parenthood until you are a parent.

    I have spent the last decade training in the MNRI method which has been a game changer for the lives of my children and my clients. I am a core in training in the MNRI program.  

    I have applied my MNRI training with children, adolescents, infants including medically fragile babies in NICU, and adults in emotional crisis.

    I am also a certified emotion code practitioner with the Discover Healing Program and Usui/Holy Fire Reiki Master with Affiliate Reiki Membership Association. 

  • Schedule:  Session length varies depending on intervention.  Typical in person intervention is 60 minutes.  Intensive intervention sessions can be 90-120 minutes.  Sessions are scheduled by appointment. To schedule an appointment contact me at 561-386-4756 or holisticfamilyOT@gmail.com. 

    Fees:  Payment is private pay only and due on date of service.  Fees may be paid cash, check, zelle direct deposit, or stripe with additional processing fee. (acct: holisticfamilyOT@gmail.com).  Invoices will be provided which can be submitted to HSA account or out of network benefits.  

      
    Initial Assessment/60min - $250 direct transfer/check/scholarship/trust, invoice/reciept/superbill provided 

    Initial Assessment/60min -$230.00 cash/no receipt/invoice/superbill provided

    Intervention/60min - $130.00 direct transfer/check/scholarship/trust, invoice/reciept/superbill provided 

    Intervention/60min - $120.00 cash/no receipt/invoice/superbill provided

    Traumatic Stress Release Bodywork with Emotion Code/90min- $225

    Traumatic Stress Release Bodywork/60min- $175

    Traumatic Stress Release Bodywork/90min- $250

    Adult Primary Reflex Assessment- $250

    Emotion Code Single Session- $80

    Emotion Code Package 3 Sessions- $225

    Add'l $20 traveling fee beyond 15 mile radius from my residence 

    *All invoices for recoccuring sessions need to be paid in full by the end last scheduled session for that week

    *Invoices for single sessions need to be paid in full by end of service.  

    *Cancelation Fee- $75.00 with less than 48hrs notice to be paid prior to next scheduled appointment.

    *Text reminders are provided the day before scheduled session however if you anticipate a schedule conflict or wellness concern I will need at least 48 hours notification to allow for rescheduling.  Short notice cancellations are very disruptive to my buisness and personal schedule.  

  • CONSENT I have read all the information provided here or it has been read to me. I understand the contents of this informative consent form. I understand the risks involved in holistic occupational therapy and agree to participate in the procedures to be conducted and comply with the established plan of care set forth by my occupational therapist. I have had the opportunity to ask questions and all of which were answered to me accordingly. 

  •  - -
  • Clear
  • Should be Empty: