Matt Misuraca LMFT
74-133 El Paseo East Suite 11
Palm Desert, Ca. 92260 760-708-8253
Jirvana Workshops: Patient-Informed Consent For: Jirvana Weekend Workshops
My participation in Jirvana Workshops is voluntary. I understand that Jirvana Workshops is emotionally intense and may involve my emotions in a manner, which may result in feeling of anger, depression, anxiety and emotional distress. I agree to accept such risks and assume the responsibility for any such emotional distress and/or other effects of my participation.
I understand that some program components may involve private transportation to and from nearby restaurants for meals. I have discussed any health concerns with Matt or Maureen, and I have agreed to discuss any health concerns with my primary doctor, and my doctor and I feel my health is good enough to participate in the program.
I understand that participation in any of these activities contains certain risks of bringing up emotionally painful memories. I agree to assume fully any and all risk arising from my participation in Jirvana Weekend Workshop.
Jirvana uses Experiential Therapies that have been researched and shown effective in relieving symptoms of PTSD and Trauma, and help with changing Codependent behaviors. There are no miracle cures; we cannot promise that your behavior or circumstances will change. I can tell you we will support you over the weekend, and do our best to help you understand your repeating patterns, as well as help you clarify what it is that you want for yourself, and help you form a successful after care plan.
The cost for Jirvana Workshops Weekend is $1080 for the weekend We require a deposit of $350 to hold your space in the weekend, and payment in full is due 2 weeks prior to your scheduled weekend (unless other arrangement for payment have been made). Jirvana Weekend payments are Non-Refundable. You are however, able to use your deposit of $350 or total payment of $ 1080, for a future Jirvana Weekend Workshop, for up to, one year from the date of your scheduled workshop. We do not take insurance for Jirvana and no super bills will be issues for Jirvana. Jirvana Workshops is a fee for service business only, and unable to provide any other documentation, notes, summaries etc. to any third party request.
Client agrees to participate in Jirvana Workshops with the understanding of the following:
- You may no longer exhibit emotional distress when recounting the incidents you work on.
- High level of disturbing emotions can occur while do your work.
- Negative feelings may get more intense before they get better.
- It is client responsibility to put appropriate safe guards in place if
you are dealing with compulsions, or addictions, or impulsive behaviors.
- You can be triggered to act out in your addiction/compulsion if we activate disturbing memories, so use your recovery tools, meetings, sponsor, journal, therapy, etc...
- Jirvana is a beginning and more therapy and aftercare is recommended.