TRINITY LANE ELECTRONIC INFORMED CONSENT FOR ADULT:

Practitioner(s): Christina N. Lane, RN, RMT, Amy Hatch, Kellie Surdis

This is a legally binding agreement between the above-named practitioner(s) and I, the client, named below. 

The services to be provided by the practitioner(s) to I, the client, may include any or all of the following: Reiki, Angel Messenger Card Readings, Tapping, other available holistic treatments not listed here, as determined jointly prior to sessions. All information shared is strictly confidential and I, the client, am encouraged to ask questions at any time. I, the client, acknowledges that treatments involve close proximity and/ or physical touch from the practitioner(s) to I, the client, only. I, the client, am encouraged to express any feelings of physical or emotional discomfort or unease should they arise. I, the client, acknowledges that sessions are not guaranteed to cure, treat or provide relief from any disease or symptom. I, the client, release the above named practitioner(s) from liability in the unlikely event of any physical or emotional injury or distress that may occur.

Disclosure: Although a practitioner may hold a board certification or license in Nursing, it is important that I, the client, am aware the practitioner will not be functioning in this role for the purpose of treatment sessions.  General guidance on health and well-being may be given. However, I, the client, acknowledges the practitioner is not a licensed counselor, nutritionist or massage therapist. All concerns regarding medical or mental health conditions should be directed to the I, the client’s, regular health care practitioners.

Appointments: Sessions are 50 minutes in length. Out of mutual respect, a 24-hour cancellation notice is requested. If 24-hour notice is not given, the full cost of the session is still due. As unforeseen circumstances arise, exceptions may be made upon discretion of the practitioner. If I, the client, arrive late for a scheduled appointment, practitioner(s) will do our best to accommodate. However, in respect for all, practitioner(s) do not guarantee that you will receive your full treatment if you are late to your scheduled appointment.

Communications: Acceptable forms of communication include text, call, e-mail, or messaging through social media and/or trinitylane.us. Please allow up to 24 business hours for a response. I, the client, am encouraged to reach out again if no reply is received within that time frame.

Privacy: Any information shared between practitioner and I, the client, is strictly confidential.

I, the client, am aware that practitioner(s) are mandated reporters in the commonwealth of Massachusetts and this confidentiality may be broken if I, the client, is at risk of harm and/or if I, the client am at risk of harming myself or others.

Any communication between practitioner(s) and any third party requires expressed written consent of I, the client, or parents/ guardian if the client is under 18, unless required by law.

Payment: Acceptable forms of payment include cash, Venmo or credit card. Trinity Lane is unable to accept health insurance or flexible spending account funds. Payments are expected at the time of visit.

I, the client, understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation.  I, the client, understand that Reiki practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, nor interfere with the treatment of a licensed medical professional. I, the client, understand that Reiki does not take the place of medical care. It is recommended that I, the client, sees a licensed provider or licensed healthcare professional for any physical or psychological ailment that I, the client, may have. I, the client, understand that any wellness discussions and/or recommendations that arise during a reiki session must be reviewed and consented to by a licensed physician prior to initiating any change in I, the client's health and wellness. I, the client, understand that Reiki can only complement any medical or psychological care I, the client, may be receiving, but does not take the place of traditional medical care. I, the client, also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I, the client, acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. I, the client, have read this statement of policy and understand its contents. I, the client, have asked any questions I, the client, may have about these policies and voluntarily consent to holistic sessions with Christina Lane, RN, RMT, and/or Amy Hatch, and/or Kellie Surdis under the terms described above and acknowledge that I , the client, have the right to terminate this agreement should I, the client, no longer wish to receive holistic treatments from Christina Lane, RN, RMT and/or Amy Hatch and/or Kellie Surdis. I ,the client, acknowledge that I, the client, have been offered a copy of HIPAA (Notice of Privacy Practices for Protected Health Information). (Please see copy of HIPAA below)

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION:

No information about any client will be discussed with any third party without written consent of the client or parent/guardian if the client is under 18, unless required to do so by law. Any information from a Reiki session between practitioner and client may be kept as physical and/or electronic records to facilitate treatment of stress reduction and/or relaxation for each client. All personal information will be kept strictly confidential to the best of the practitioner’s ability.

Client Name:____________________ Client Signature:____________________ Date:_________________

Provider Name:____________________ Provider Signature:____________________ Date:_________________