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Nicole Kempskie 347 5th Ave. Apt. 1L Brooklyn, NY 11215 www.Sanctuaryholistichealing.com Nicole@sanctuaryholistichealing.com 917-822-0227 INFORMED CONSENT FORM Welcome to my practice! Before we proceed, I want to make sure that you have sufficient information to feel comfortable entering into a professional relationship with me. Please read and sign this form, and let me know if you have any questions or concerns. If you decide to proceed and sign this document, it will represent a formal agreement between us. WHAT IS ENERGY MEDICINE? Energy Medicine is an approach that involves balancing and restoring your body’s natural energies for the purposes of increasing your vitality, strengthening your mental capacities, and optimizing your health. The form I use was developed by Donna Eden and is described in her book, Energy Medicine. The state of New York does not offer a license specifically mentioning the practice of Energy Medicine and Energy Medicine is not specifically regulated by any federal or state regulatory agency in the USA. LIMITATIONS: ENERGY MEDICINE IS NOT THE PRACTICE OF MEDICINE Although Energy Medicine uses the term “medicine,” it does not imply that Energy Medicine practitioners are practicing medicine. Energy Medicine is a term used by many training programs that teach people how to assess and correct for energy imbalances in the body. Energy Medicine is not a substitute for the diagnosis and/or treatment of medical or mental health conditions by a licensed health care professional. If you have a disorder that has been diagnosed by a licensed medical or mental health professional or a condition that should be evaluated by a licensed health professional, my services should be used only in conjunction with your obtaining that care. I do not diagnose or treat medical or mental health disorders, nor am I trained or licensed to do so. It is your full responsibility to seek medical advice and opinion from your primary care physician (or other qualified health care provider as appropriate) regarding regular assessment and routine monitoring of your medical health or if you have symptoms MY BACKGROUND AND TRAINING I am a Certified Eden Energy Medicine Practitioner (EEM-CP). The Eden Energy Medicine Certification Program consists of two years of intense study and supervised practice. In addition, I hold a M.A. in Interdisciplinary Studies from New York University and a B.A. from Providence College (Summa Cum Laude). I am a published writer and playwright, a professional theater and dance artist, and have been an educator and facilitator for 15 years. OUR WORK TOGETHER: DESCRIPTION OF SERVICES You can expect me to approach my work with you in a professional manner, to honor scheduled appointment times, and to treat information I learn about you as confidential.

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My sessions last 60-90 minutes in length. During this time we will briefly discuss your concerns and reasons for consultation, and review what has occurred since the previous session. Clients are expected to provide accurate and complete information that will assist me in assessing potential energy imbalances in the subtle energy fields. We will then begin a process where I assess the flow of energies in your body and facilitate corrections designed to bring disturbed energies back to a state of balance and harmony. I’ll use muscle-response testing as a method to assess your body’s energies, also known as energy kinesiology. I will use various forms of light and deeper touch, along with movement of my hands within your energy fields, to balance and harmonize your energies. If you are uncomfortable with being touched or with any of the procedures being used, please tell me immediately. I will always honor any requests not to touch. While the methods I will be using are gentle and considered non-invasive, it is possible that physical or emotional after-effects may occur after your energies have been stimulated and adjusted. In some instances, deeper pressure is used to move energies that may be blocked or congested in a particular area of the body, and this may cause some pain or discomfort. Dizziness, nausea, or anxiety are relatively unusual but not unheard of side-effects to energy work. If any procedure is uncomfortable or leads to discomfort, please tell me at once. I will instantly stop if you request me to do so and can often provide a technique to counter the discomfort. TIMELINESS It is important that you are on time for your appointment. If you are late, that time is lost from your session and the remaining time may not be sufficient to address the issues of your consultation. If I am late for a session, I will extend the session if our schedules permit, or we will make other arrangements. SESSION FEES My fee for a session is $120 for a 60-minute session and $150 for a 90-minute session which is due at the time of your visit. Payment is by check, cash, or online via credit card. I will provide you with a receipt each time you pay if requested. DRESS CODE It is best to wear loose comfortable clothing, and I’ll ask you to remove your shoes to be able to do energy work on your feet CANCELLATION POLICY I require at least 24 hours notification of cancellation. Otherwise, you’ll be billed and expected to pay for the missed session. CONFIDENTIALITY Your records, files, personal information and experiences during our EEM sessions are strictly private and confidential. You may instruct me to release information to other health care practitioners or I may be required to release information if subpoenaed or otherwise legally obligated such as in circumstances where there is clear and imminent danger to yourself or another person. After a period of 5 years from the date of suspension of service and session, I will shred and destroy all records and copies relating to your participation in EEM session/s while in my practice. 2


ACKNOWLEDGEMENT AND CONSENT TO RECEIVE SERVICES I have read and understand the above disclosure regarding the services offered by Nicole Kempskie. I understand that she is not a physician and that her services as an EEM-CP are not licensed in the state of New York. I further understand that Nicole Kempskie is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies. I have consented to use the services offered by Nicole Kempskie, and agree to be personally responsible for the fees in connection with the services she provides me. That includes full payment for a session I miss without providing 24 hours notice. I also agree to be personally responsible for my own health recognizing that the degree to which energy can heal depends upon my participation. Provided I am informed it is necessary, I consent to the release of confidential information relating to me or my child, if the release of that information: a) follows a statutory requirement, a Court Order, or a legal duty; b) is to a mental health professional, clinician, or a medical practitioner as part of a referral process initiated by myself or Nicole Kempskie; c) is for the purpose of discussing my case history or that of my child, with my medical practitioner or any former clinician or psychologist/mental health practitioner who has provided services to me or my child; d) in the opinion of Nicole Kempskie, may prevent the commission of a serious crime and/or harm to a third party and/or harm to me or my child; e) is reasonably required. Your signature below indicates that you have read the information in this document, understand it fully, and have discussed any questions or matters of concern with me.

_______________________________________ Print Name _______________________________________ Signature

_________________________________ Date

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Sanctuary Informed Consent Form  
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