Client Intake Form & Informed Consent

Welcome

Before filling out the intake form, please read the Informed Consent documents further down this page. They explain the nature of my practice, the risks and benefits of the work, and my business policies.

By submitting this intake form you agree to the contents of the Informed Consent documents that apply to your sessions. This form and the informed consent documents act as a contract between you and me for our session work.

Please complete the intake questions at least 48 hours before our first session.

Session Details

Session length

  • 60- 120 minutes online, via Zoom

  • 60–75 minutes in person (please schedule [75] minutes; we may not need all of it)

If we are meeting online:

Zoom address: [Zoom link]

Getting ready

  • Make sure your camera and microphone are working.

  • A laptop or desktop is preferable to a mobile phone.

  • In Zoom settings, please select "Speaker" view and pin my image, rather than Gallery view, so you are not looking at yourself during the session. I can help if you're unsure how.

  • Please be seated in a quiet, private place.

  • Depending on the kind of session, it can help to have a place to lie down, such as a bed, sofa, or mat.

If we are meeting in person

Address: 33325 Pacific Way, Fort Bragg CA, 95437

What to wear: No special clothing is required. Please dress comfortably.

Accessibility: The studio is on the same level as ground but there are a few steps on the initial deck before the entrance. Please let me know if you need any help with those external steps.

Parking: Once you arrive to the parking spot and mailbox address, please continue to the next driveway of the same fenced property on the left side. There is parking anywhere there. Entrance to my studio is the white door on the deck.

When you arrive: Please be ready to arrive a little early or on time. Upon arrival and at the time of our appointment, you are welcome to knock on the door of the studio and I will let you in immediately.

Payment

Fee: $160 - $100 per session. The Safe and Sound / Rest and Restore Protocol has its own fee, described in its consent below.

Payment methods

Payment policy: Payment is due before or right after the appointment.

Cancellation payment: If you cancel with less than 24 hours' notice, payment is due immediately.

Cancellation & Rescheduling

Notice requirements: Cancellations or reschedules with more than 24 hours' notice incur no charge. Cancellations or reschedules with less than 24 hours' notice are charged the full session fee, payable at the time of cancellation. No-shows also incur the full session fee.

Preferred notice: Whenever possible, I appreciate more than24 hours' notice if you need to cancel or reschedule. If an in-person session is not feasible, an online session is always an option.

Late payments: Outstanding balances must be settled promptly.

Provider cancellations: Occasionally I may need to reschedule. If this happens, I will notify you in advance and make every effort to find a time close to your regular appointment.

Ongoing Appointment Policy

Consistency in scheduling: Upon meeting, clients are asked to establish a regular appointment schedule: weekly, biweekly, or every four weeks. I do not currently offer as-needed sessions except during the initial trial period. After that period, I only see clients who can commit to a regular schedule.

Rescheduling needs: To maintain continuity of care, if you cancel an appointment, I ask that you reschedule within the same time period (for example, within two weeks on a biweekly schedule). This honors the agreed-upon frequency of sessions.

Frequent changes: If cancellations or reschedules become frequent, we may need to adjust your appointment frequency or discuss releasing your regular time slot. Before making changes, we can explore scheduling alternatives that support your needs.

Client Intake Questions

Please complete this at least 24 hours before our session. Items marked * are required.

Somatic Experiencing® Informed Consent

When appropriate, and according to my experienced judgment, I will use Somatic Experiencing (SE) in our work together. SE is a naturalistic approach to the resolution and healing of trauma developed by Dr. Peter Levine and is supported by research. It is based upon the observation that wild prey animals, though threatened routinely, are rarely traumatized. Animals in the wild utilize innate mechanisms to regulate and discharge the high levels of energy arousal associated with defensive survival behaviors. These mechanisms provide animals with a built-in "immunity" to trauma that enables them to return to normal in the aftermath of highly "charged" life-threatening experiences.

  • SE employs awareness of body sensation to help people "renegotiate" and heal rather than re-live or re-enact trauma.

  • SE's guidance of the bodily "felt sense" allows the highly aroused survival energies to be safely experienced and gradually discharged.

  • SE may employ touch in support of the renegotiation process.

  • SE "titrates" experience (breaks it down into small, incremental steps), rather than evoking catharsis, which can overwhelm the regulatory mechanisms of the organism.

For further references and information online about SE, go to: www.traumahealing.com

SE can result in a number of benefits to you, such as relief of traumatic stress symptoms, increased resiliency, and resourcefulness. Like any other treatment it may also have unintended negative "side effects." As with all therapy, it is your responsibility to tell me when you are uncomfortable with any parts of the treatment. If you have any questions about SE or other treatments, please ask and I will do my best to answer your questions in full. You have the right to refuse or terminate treatment at all times, or to refuse techniques or interventions I may propose or employ.

I have read the above informed consent, understand, and agree to it.

Safe and Sound Protocol (SSP) and Rest and Restore Protocol (RRP) Informed Consent

Introduction and benefits

Thank you for agreeing to participate in the Safe and Sound Protocol/Rest and Restore Protocol. This intervention is evidence based, which means that it has been found through research to have a positive impact on individuals who participate in it. I am hopeful it will be helpful for you as well.

The Safe and Sound Protocol (SSP) and Rest and Restore Protocol (RRP) are a result of Dr. Stephen Porges' forty years of research on the relationship between the autonomic nervous system, auditory sensitivities and social emotional processes. The SSP (5 hours of music) and the RRP (10 hours of music) are sound-based interventions that have been found to calm physiological and emotional states. They were designed to reduce stress and auditory sensitivity and enhance social engagement and resilience by stimulating nervous system regulation via Ventral Vagal Activation (SSP) and Enteric Nervous System/Gut (RRP). This is accomplished by exercising and systematically challenging the auditory system with specifically processed or filtered music.

You will be seated or lying down while listening to this music for 10 minutes or less. In the event that we determine it therapeutically prudent to stop the music before it finishes on any given day, we will spend the remaining time facilitating nervous system settling. We will resume the SSP or RRP the following time. This fine-tuning of the protocol is quite normal and is to ensure your safety.

What is involved?

If you decide to participate you will attend a series of 1 hour appointments (with 10 or fewer minutes of active listening plus time for instruction/discussion) to receive the SSP/RRP+SE or Biodynamic Craniosacral Therapy intervention. While listening, you will engage in a relaxing non-verbal activity, rest, and/or receive gentle somatic support. As the purpose is to support feeling safe, you are encouraged to utilize any "props" that will make your experience more comfortable (special blankets, drawing pad, journal, knitting tools, puzzle, etc.).

The SSP and RRP are most effectively administered in silence. We will avoid talking during the intervention, but can communicate as necessary via gesture or written note. You will be holding the player device via the Unyte app on your phone and will have the ability to pause the music as necessary in order to make the experience as safe-feeling as possible.

I will also be with you (live or online) and will be monitoring the entire intervention.

Risks

Because the SSP and RRP work with the vagus nerve or gut, there is the possibility that you will experience some temporary gastrointestinal symptoms (for example, bowel changes or gas). You also may experience an uptick in strong emotions or auditory sensitivity for a short time. In part, this is due to the fact that the interventions are "changing" the nervous system into a more settled state, but because this "feels" different, it can be disorienting. As time passes, you should settle into the new, calmer state.

The SSP and RRP may be considered Somatic Intensives. It's best to select a time period which avoids extra external stressors (traumatic anniversaries, new beginnings, etc.), and to keep unnecessary activities and stress to a minimum as long as we do the sessions and the week or so following completion of the SSP/RRP treatment. It is quite common to feel physically tired during and after the intervention, so getting adequate rest is very helpful. There may also be other risks that I cannot predict. If you experience any adverse effects, please contact me immediately so that I can offer support.

Your rights

Participation in this intervention is voluntary. You have the right to end your participation at any time. Your confidentiality rights are the same as in a counseling or coaching relationship.

Responsibilities

Because each time of the protocol requires listening to a specific timing of music, it is imperative that we adhere to the schedule we establish and begin on time.

The cost of the annual subscription to the SSP and RRP systems separately is $350 (does not include headphones and one-on-one sessions), payable ahead of the first appointment. If you do not attend all sessions you will forfeit the remainder of your payment. In the unlikely event we determine it appropriate to discontinue the intervention, a partial refund may be requested.

I understand the risks and benefits associated with the Safe and Sound Protocol (SSP) and with the Rest and Restore Protocol (RRP) and agree to participate.