CLIENT AGREEMENT

Thank you for your interest in working with me as a client. Please read this information carefully and ask any questions you may have before signing this agreement.

1. Phone calls: Calls are returned Monday through Friday, all calls will be returned within 1 business day. Please leave your phone number and first name with your message.
2. Emergencies: If you have an emergency please call 911 or go to your nearest Hospital Emergency Room. If you feel I need to be made aware of the situation please call me after seeking appropriate emergency care.
3. Cancellation policy: If you fail to cancel a scheduled appointment, I cannot use this time for another client. Therefore, you will be billed for the entire cost of a missed appointment.

A full session fee is charged for missed appointments or no show cancellations with less than a 24 hour notice. The full session fee will be added to the next session, if a credit card is not on file.

If the client(s) does not show for the next session, a bill will be mailed directly to clients who do not show up for a following appointment.

4. Billing: The following billing policies apply:
a. Fees for sessions are due at the time of service. I accept cash, check, and credit cards. There will be an additional $10 fee for returned checks due to non-sufficient
funds.
b. In the event I am unable to collect on your account, be advised that uncollected fees may be turned over to the collection agency. Only necessary information will be released to them. Please be assured that I will make every effort to work with you before this happens.
5. Standard Fee: Fees vary by service type. The client is expected to pay the full fee amount unless a prior sliding fee scale arrangement has been made.

By signing below you are agreeing to the following statements:
A. I agree to pay for services, in full, at the time that the service is rendered in person. Or by online invoice prior to the session for online sessions. Fees may be adjusted periodically and I understand this will be discussed with me first.

B. I have read and understand the Billing Policy as stated in the “Client Agreement” form. In addition, I understand that I will be limited to pay by cash or credit card if I have a returned check.

C. I have read and understand the Phone Call, Emergency, and Cancellation Policies as stated in the “Client Agreement” form.

D. I agree to pay the full session fee if I miss a session or cancel less than 24hrs before the appointment time. 

 

CONFIDENTIALITY

Contents of all sessions are considered to be confidential. Both verbal 
information and written records about a client cannot be shared with another party
 without the written consent of the client or the client’s legal guardian. Noted exceptions
are as follows:


Suicide/Homicide:

When a client discloses intentions or a plan to harm another person, the practitioner is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan to harm themselves, the practitioner is required to notify legal authorities and make reasonable attempts to
 notify the client's emergency contact.

Abuse of Children and Vulnerable Adults:
If a client states or gives reason to suspect that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse by the client or another party, the practitioner is required to report this information to the appropriate social service and/or legal authorities.

Minors/Guardianship:
Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.

Legal:
To respond to a subpoena from a court.

Client’s Request:
You always have the right to request a release of records for yourself or for another helping professional.

DISCLOSURE STATEMENT

 

Theoretical Approach

I am an inner healing practitioner. This method incorporates intercessory, guided, and listening prayer as a way of addressing spiritual and emotional blocks. The two models of inner healing prayer I use are called Elijah House, Sozo, and HeartSync. All of these models draw from Biblical promises and teaching to inform their approach to prayer. Another of my methods of inner healing is called Splankna Therapy. It is a biblically based protocol for energy psychology. “Energy Psychology” utilizes the same system in the body that acupuncture and chiropractic are based on to resolve unbalanced emotions that are stored in the body. “Energy Techniques” is a collective term used to refer to a variety of methods based on the use, modification, and manipulation of energy fields that look at imbalances within the person’s energy system as well as the energetic influence of thoughts, beliefs, and emotions on the body. The prevailing premise of the Energy Techniques is that the flow and balance of the body’s electromagnetic and more subtle energies are important for optimal physical, spiritual, and emotional functioning. Splankna Therapy is designed to help get to the origin of an emotional issue with the goal of rapidly desensitizing the emotional stress connected to a past event. Splankna Therapy incorporates elements from several newly-emerging energy-based psychotherapy, coaching, and self-help techniques, specifically Neuro-Emotional Technique, Thought Field Therapy, and Eye Movement Desensitization and Reprocessing. Prayer is intertwined throughout the protocol with a deep emphasis on trusting the lead of the Holy Spirit. Basic biblical principles are also incorporated such as confession, repentance and forgiveness.

Inner healing prayer sessions are available in person and via secure online video calls. Splankna sessions are only available in person.

Although energy techniques like Splankna Therapy and spiritual approaches like inner healing prayer appear to have promising emotional, spiritual, and physical health benefits they have yet to be fully researched by the Western academic, medical, and psychological communities and, therefore may be considered experimental. These techniques are self-regulated and they are considered alternative or complementary to the healing arts that are licensed in the State of Georgia. Because Energy Techniques are relatively new healing approaches, the extent of their effectiveness, as well as their risks and benefits, are not fully known. If you ever have questions or concerns about the nature of the theories, methods, approaches and/or techniques I use, please feel free to ask me for further resources or references.

 

Outcome Expectations/Risk & Benefits/Treatment Plan

Please note that it is impossible to guarantee any specific results regarding your goals using any of the approaches I offer in my practice and I cannot know how you will personally respond to any of the approaches. However, we will work together to achieve the best possible results for you. Our work together requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. You will have to work both in and out of our sessions. I will ask for your feedback and views on our work and its progress, and will expect you to respond openly and honestly. As with any intervention, there are risks associated with Energy Psychology and Inner Healing Prayer.

Risks might include remembering, talking about, or experiencing unpleasant events which results in uncomfortable levels of feelings like sadness, guilt, anxiety, anger, frustration, worry, etc, or experiencing anxiety, depression or insomnia, etc., or having difficulties with other people. Being confronted with your difficulties can be very challenging. Some changes may lead to what seems to be worsening circumstances or even losses. In addition, if you choose to engage Splankna Therapy or Inner Healing Prayer, emotional or physical sensations or additional unresolved memories may surface which could be perceived as negative side effects. You may experience some temporary emotional distress and physical discomfort related to prior life experiences.

 

If we are to work together we will need to specify methods, risks and benefits of treatments, the approximate time commitment involved, costs and other aspects of your particular situation. We will discuss a plan that seems most appropriate to help you reach your goals. However, regardless of our work together, you agree to take full responsibility for your self-care in the emotional, mental, physical, and spiritual dimensions of your life.

 

Other Important Information

Please be advised that I am not a licensed mental health professional and the approaches I offer are not intended to be a substitute for medical diagnosis or psychotherapy and they do not replace the services of a licensed physician or licensed psychotherapist. You agree and understand it is your responsibility to consult with your physician/psychiatrist for any specific medical problems. Further, you understand I may suggest you contact your physician or psychologist/psychiatrist if I believe it’s advisable. In addition, you understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing your physician or using prescribed medication, if any, without consulting with your physician/psychologist, even if after a session it appears and indicates that such medication or treatment is unnecessary.

 

Use of Touch

You understand the application of Splankna Therapy includes light touch on the back of the wrist. Touch can be a potential problem in a support relationship if you feel it is inappropriate. If you have any misgivings, doubts, or any negative reactions to any physical contact, it is very important that you let me know as soon as possible so that we can discuss your concerns. You understand you have a choice about these techniques that involve touch.

Online Sessions

Online sessions are conducted via video call through www.doxy.me Doxy.Me is HIPPA compliant and does not require any software downloads to use. Chrome or Firefox browser is required as well as a computer with a reliable internet connection, webcam, and microphone. Doxy.me also has a free app for iOS and Android if you prefer that option. 

Leah will conduct online video calls from a private office to ensure confidentiality. It is your responsiblity to be in a private confidential environment for the duration of your call. 

In the event of technical difficulties Leah will attempt to reach you at the phone number you provided on your intake form. If she is unable to reach you that will be the end of the session. 

If technical difficulties on your part result in the session being unable to start or finish there will be no refund.

If technical difficulties are on Leah's part a full refund will be given for sessions lasting less than 5 minutes and a pro-rated refund will be given for sessions lasting longer than 5 minutes. 

 

Leah's Education and Training

Graduate Elijah House School of Prayer Ministry
Trained in basic and advanced Sozo Inner Healing Prayer
Trained in basic HeartSync
Certified Splankna Practitioner
MA, Professional Counseling, Liberty University

 

Acknowledgment and Consent to Receive Services

By signing this document and any attachments hereto, you agree that I have disclosed to you sufficient information to enable you to decide to undergo or forgo any of the approaches and other services I offer. You understand that your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. Further you understand that Splankna Therapy is a relatively new healing approach and the extent of its risks and benefits are not fully known and you agree to assume and accept full responsibility for all risks associated with using Splankna Therapy and Inner Healing Prayer. You represent that you’re competent and able to understand the nature and consequences of our proposed sessions and agree to be personally responsible for the fees related thereto. You have read and understand the above disclosure about the services offered by me and my training and education and you have discussed with me the nature of the services to be provided, and except in the case of gross negligence or malpractice, agree to release, indemnify, hold harmless and defend Splankna Therapy Institute and Leah Lesesne, its owners, managing partner, members, employees, representatives, and, consultants from and against any and all claims or liability, of whatsoever kind or nature, which you, or your representatives, may have for any loss, damage, or injury, including without limitation, physical, emotional, mental, financial, or personal, arising out of or in connection with your sessions.

 

 

CONSENT TO SERVICES

By signing this Client Information and Confidentiality, Disclosure, and Consent Form, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive services for me, and I understand that I may stop such services at any time.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Leah Lesesne and Shelemah LLC from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).