I, the undersigned parent or legal guardian, understand that Kate Clemons is not a licensed medical doctor and does not portray herself to be one. I acknowledge that she cannot diagnose, treat, cure, or prevent any nutritional, medical, or psychological disease, disorder, or condition. She cannot advise, recommend, suggest, or counsel on any medical, dietary, or psychological treatment, condition, disorder, or disease, or perform any act that would constitute the practice of medicine for which a license is required.
I understand that the purpose of the biofeedback session for my child is to support relaxation, stress reduction, energetic balance, and overall wellness. The goals of infant biofeedback may include:
- Supporting the infant’s natural ability to self-regulate
- Assisting with relaxation and calming
- Encouraging healthy stress responses
- Supporting the body's innate healing processes
I understand that biofeedback is generally considered gentle and non-invasive, but it is possible for emotional or energetic shifts to occur during or after the session. I agree to promptly inform Kate Clemons of any noticeable changes or concerns.
I understand that biofeedback is not a substitute for standard medical care. I am advised to maintain regular pediatric visits and medical care for my child. I understand that no guarantees of outcomes are given or implied.
Confidentiality
I understand that all information shared during sessions, or discovered during biofeedback assessments, will be kept in strict confidence, except when required by law or if I provide written permission to share information with other healthcare providers.
Parental Responsibility
I acknowledge that as the parent or legal guardian, I am solely responsible for the healthcare decisions concerning my child. I understand that by consenting to these services, I am exercising my right to seek complementary and alternative wellness options for my child.
I also understand that I must remain present during the session and that it is my responsibility to inform Kate Clemons of any known medical conditions, allergies, or special needs prior to the start of the session.
Cost and Payment Policy
I understand that the cost of a pediatric biofeedback session is $250 for a 2-hour consultation.
I am welcome to pay the full session amount at this time if I prefer.
Payments may be made via cash, credit/debit card (+3%), Venmo or CashApp
Venmo: @KateClemons14
Cashapp: $KateClemons14
I acknowledge that biofeedback services are typically not covered by insurance.
Agreement to Arbitrate
I agree that in the unlikely event of a disagreement that cannot be resolved amicably, both parties agree to resolve the matter through binding arbitration under the laws of the State of Texas.
Authorization
By dating below, I acknowledge that I have read, understood, and agreed to the information above. I voluntarily consent to biofeedback services for my child with full knowledge of the nature and purpose of the services. I acknowledge that I will review and sign the full consent form in person at the time of my appointment, and that a signed copy will be kept on file for record-keeping purposes.