Berkshire Biofeedback
Stress, Pain & Energy Management
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Consent Form


Biofeedback Consent Form

 

Consent to receive biofeedback from Barbara Laureyns (Berkshire Biofeedback)

 

I understand Barbara Laureyns (Berkshire Biofeedback) is a Certified Biofeedback Technician and that she may train me with biofeedback for relaxation and muscle re-education so I may learn to reduce my stress, manage my pain, and/or improve the quality of my life.

 

I understand Barbara Laureyns (BBF) is Certified as a Spiritual Healing Coach.  This is the ability that may help me to reconnect to the divine power within myself.

 

I understand Barbara Laureyns is a Certified Biofeedback Technician (BFT) who uses Biofeedback to help me relax and manage stress, re-educate muscle and/or manage pain.

 

I understand Barbara Laureyns is a Certified Spiritual Healing Coach (SHC) who may empower me through coaching so I can make informed decisions about my own life and health care. I also understand she does not diagnose, treat, prescribe, counsel or attempt to cure any medical, mental, psychological or physical conditions.

 

I understand that I am responsible for my own health, healing and well being. I also understand I have the ability to heal myself. I further understand Biofeedback is not a substitute for adequate medical care and I intended to remain under the care of my primary healthcare provider. I understand I have the ability to heal myself by reconnecting to the source of all healing, The Devine whoever that is for me.

 

I understand all healing may cause me some minor discomfort and some adverse side effects may occur through no fault of myself or Barbara Laureyns (BBF).

 

I will keep Barbara Laureyns (BBF) fully advised about my concerns so the intervention may be terminated if necessary or revised to minimize any harm to me.

 

Biofeedback Consent Form

 

I understand Barbara Laureyns (BBF) will keep all information she learns about me completely confidential unless I release her in writing or as required by law. I further understand Barbara Laureyns (BBF) will not acknowledge my presence or discuss anything with me publicly unless I initiate the conservation and the topics of discussion.

 

I agree to settle any disagreements I have with Barbara Laureyns (BBF) and if this is not possible, then I agree to turn our concerns over to Natural Therapies Arbitration Council to mediate an agreement acceptable to both myself and Barbara Laureyns (BBF).

 

I understand Barbara Laureyns (BBF) charges an hourly fee of $60.00 payable by credit card, cash, check or money order at the time services are delivered. In the event my check is not honored by her bank, I agree to pay an additional fee for $25 for this inconvenience.  Discount packages are available please inquire.

 

I acknowledge that I have read and understand this form. I agree to allow Barbara Laureyns (BBF) to help me allow and accept Divine healing using Spiritual healing techniques and Biofeedback.

 

Pricing: $60 per 1 hour session

 

Biofeedback Consent Form

 

 

Name: (Please print): _________________________________________________

 

Address: _____________________________________________________________

 

 

 

Phone: _________________________________________________________________

 

Email: ________________________________________________________________

 

Date: ____________________________

 

Signature: ____________________________________________________

 

Cancelation Policy

 

You MUST cancel or reschedule two (2) full days in advance or you will be charged for the session.  If you have something that comes up I would be willing to discuss the situation and it will be up to Berkshire Biofeedback’s decision to charge for the session or not this will be determined on a case by case basis.

 

 







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