I understand that Kate Clemons is a wellness practitioner and not a licensed medical doctor, dietician or nutritionist. Kate Clemons does not diagnose, treat, cure, or prevent any medical, psychological, or nutritional conditions or disorders. I acknowledge that Kate Clemons is not qualified to provide medical advice or perform acts that would require a medical license.
Purpose of Biofeedback Training
I understand that the primary purpose of biofeedback training is to help manage stress, support pain management, and improve overall well-being. Biofeedback may assist in:
- Reducing stress
- Managing pain and discomfort
- Enhancing quality of life
While biofeedback is generally considered safe, I acknowledge that there may be occasional temporary side effects, including but not limited to drowsiness or exacerbation of emotional stress. I will inform Kate Clemons immediately if I experience any discomfort or side effects during or after a session to allow for corrective actions if necessary.
No Substitution for Medical Treatment
I understand that biofeedback is not a substitute for conventional medical care and that Kate Clemons has advised me to continue any ongoing medical treatments or therapies unless otherwise directed by my physician. I acknowledge that biofeedback may potentially lead to changes in my medications, but I understand there is no guarantee that it will reduce or eliminate any medications. If I do not have a primary care doctor, I will ask Kate Clemons for assistance in locating a healthcare provider.
Confidentiality and Privacy
I understand that any personal information shared with Kate Clemons, including information about my health and wellness, will be kept strictly confidential, except as required by law or with my explicit written consent. I have the right to waive this confidentiality agreement in whole or in part at any time. I also understand that I may give written permission to Kate Clemons to communicate with my primary care provider or any other specialists regarding the biofeedback training and any results I may experience. I have the right to withdraw this permission at any time.
Informed Consent
I have voluntarily chosen to seek biofeedback services provided by Kate Clemons and fully understand the nature of the services being provided. I acknowledge Kate Clemons' qualifications and certifications. I understand that the sessions are for wellness enhancement, stress reduction, and relaxation, and that I am not receiving medical diagnoses or treatments. I am seeking biofeedback training solely for the purpose of improving my health and wellness.
Disclosure of Affiliation
I agree to immediately inform Kate Clemons if I am a government official, or if I represent or am affiliated with any media company or corporation. I understand that my permission to receive services is contingent upon such disclosure, and failure to disclose may be considered fraudulent.
Arbitration Agreement
In the event that Kate Clemons and I cannot resolve any disputes, we both agree to submit to binding arbitration under the laws of the State of Texas. The decision of the arbitrator will be final and binding. Any disputes will be handled through arbitration and not through litigation.
Acknowledgment of Understanding
I hereby affirm that I have read and understood the terms of this consent form and that I am providing informed consent to receive biofeedback services. I understand that I may withdraw from this program at any time. 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.
Cost of Biofeedback Services
I acknowledge and agree that the cost of biofeedback sessions is $250 for a 2-hour initial consultation and $175 for a follow-up.
Cancellation and Rescheduling Policy
I understand that if I need to cancel or reschedule my appointment, I must provide at least 24 hours' notice.
Accepted Payment Methods
Payment is due at the time of service. Payment can be made through the following methods:
Cash
Credit or Debit Card
Venmo or CashApp
No Insurance Coverage
I understand that biofeedback services are not typically covered by insurance. I agree to pay the full session fee as outlined above. Should my insurance policy or healthcare plan offer reimbursement, I will seek reimbursement directly from my insurance provider.
Refund Policy
I acknowledge that fees for services rendered are non-refundable. If I am dissatisfied with my session or need to reschedule, I will discuss my concerns with Kate Clemons directly.