intake and informed consent — journey from seed - core energetics therapy

New Client intake form

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informed consent

Please read these over these policies and information regarding our therapeutic relationship and ask any questions you may have-- it is important that you understand them because when you sign this document it will represent an agreement between us. We can discuss any questions you have before you sign or at any time in the future.

About Therapy
Core Energetics, like any therapeutic modality, has both benefits and risks. Because the process of therapeutic work often requires recalling and discussing the unpleasant aspects of your life, risks may include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness.

However, Core Energetics also has benefits for individuals who undertake it! Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. In addition, please understand that therapy may result in decisions to change behaviors, employment, substance use, schooling, housing, or relationships. Change can sometimes be quick and easy, or sometimes gradual and even frustrating.

Signing this document means you accept that these “side effects” may occur in your life as a result of our work together.

Core Energetics, just like other forms of therapy, requires an active effort on your part. In order to be most successful, ongoing reflection outside of sessions is recommended.

Rates
I utilize an income-based sliding-scale fee structure ranging from $65 to $300 per hour based on clients’ income or access to financial resources. The specific rate for your sessions has been discussed before confirming our therapeutic relationship (typically during our consultation) and by this time has been confirmed by email. I’ll initiate yearly a check-in to ensure rates stay current with your access to resources. If you have any questions about your rate, or incur a change to your income or access to resources, please let me know. Additionally, rates are subject to periodic small increases to adjust for cost of living and inflation.

You are responsible for paying at the time of your session unless prior arrangements have been made. I accept cash, check, and digital payment methods such as Venmo, Paypal, and Cash App. If you are not comfortable using the ‘friends and family’ option when paying digitally, please bring cash or check to your sessions. We will connect during your first appointment to firm up details of which payment method you would like to use for your sessions. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover bank fees that I incur.

Because I organize my livelihood around our appointments and late cancellations end up having a significant impact on that, I charge the full appointment fee for sessions cancelled with less than 24 hours notice, and 50% of your appointment fee (with a minimum of a $50 fee) for sessions cancelled with less than 48 hours notice. No-shows will be charged the full appointment amount. Illness or emergencies that impact cancellations will be assessed on a case-by-case basis.

Other Policies
I communicate by phone or email, and typically do not communicate via text message with clients unless you are running late to an appointment or need to cancel last minute. Please do not communicate last minute cancellations via email, do this with a phone call or text (you can find my phone number in the signature area of emails I’ve sent you).

Because it is extremely important to maintain the boundaries of our therapeutic relationship I do not connect with clients on social media platforms.

Licensure Status
After 3 years of schooling and 2 years of clinical supervision, in May of 2021 I completed the certification process of Seattle School of Body-Psychotherapy. I practice counseling as a Certified Core Energetics Practitioner. I am not a therapist licensed by the State of Oregon but rather, I practice as an alternative counselor under Oregon Regulatory Statute 675.825(4)(a)

While I believe that my training is more than adequate to support the clients I serve, it is important that all potential clients understand that I am not trained nor licensed to diagnose mental health conditions, or provide treatment for a diagnosis out of the DSM. If you are seeking treatment for a DSM diagnosis, I recommend seeking a licensed practitioner that can legally offer this kind of support.

Confidentiality and Cybersecurity
Though I am not bound to do so by a state license, I do believe I have an ethical obligation to adhere to the standards of therapeutic confidentiality which dictate that I protect identifying information about my clients. Exceptions to this are if you are at high risk of being a danger to yourself (suicidal) or to others (homicidal). I will also report any incidents of abuse or neglect to the elderly and to minors under the age of 18.

Additionally, the technology I use to execute and support my practice (such as these online forms, or the video platforms I may use to do online sessions) meet HIPAA level security standards, despite the fact that I’m not considered a “covered entity” under HIPAA.

Use of Touch
Somatic or body-oriented therapy recognizes the inherent unity of our human nature with our biological organization. Somatic interventions in Core Energetics include the study of and interaction between our physical sensations, postures, gestures, thoughts, feelings, and language; and the use of touch. The use of touch is very carefully applied and fully dependent on the consent of the client. You have the right to refuse, modify, or stop any touch at any time, for any reason. Please let me know if you have any questions, concerns, or if you decide to avoid or limit, in any way, the use of touch in your sessions.

Client Rights
You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, relationship structure, age, religion, or national origin. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with current or former clients.

Additional Info
If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Your comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist, and are free to end therapy at any time. If you decide to close our container, I recommend clients schedule at least one additional meeting to review the work we have done together and how it can inform your future. I offer these final closure sessions free of charge for all clients.

Thanks for taking the time to engage with this material! Now that the nitty gritty is out of the way we can move forward with clear expectations for our healing container. Please be in touch before you sign this document if you have any questions about it’s contents or want to discuss anything further.

In signing this document I agree that I have read and will comply to the aforementioned policies regarding my treatment with lisa anne ross.