456 N. Main Street, Oshkosh, WI54901 (920) 410-4022
CONSENT TO RECEIVE WELLNESS SERVICES FROM
Kari Uselman, Ph.D.
DISCLAIMER
I understand Kari Uselman, Ph.D. is not licensed as a chiropractor, counselor, medical doctor,psychologist or psychotherapist and does not portray herself as such. I understand, shewill not diagnose, evaluate, treat, cure, mitigate or prevent any nutritional, medical orpsychological disease, disorder or condition. I further understand she cannot advise me on any medical or psychologicaltreatment, condition, disorder or disease of any kind. I further understand it is myresponsibility to continue my medications and remain under the care of my primaryphysician.
CREDENTIALS
I understand Kari Uselman, Ph.D. is a Certified Biofeedback Specialist and Homeo-Therapeutic Coach with the National Therapies Certification Board, has advanced training through Premier Research Labs in Quantum Reflex Analysis, Cation Mudpacks, Vastu Bio-Energetics and Emotional Re-polarization Technique, has taken Craniosacral Therapy and Semato-Emotional Release courses with the Upledger Institute, and has studied wellness modalities for over 20 years. I understand her modalities focus on relaxation, pain reduction, trauma release and muscle re-education so I can learn toreduce my stress, manage my pain, release trauma and improve the quality of my life. I furtherunderstand that Kari will refer me to qualified experts for any other concerns I have aboutmy health and wellness.
I understand Kari Uselman, Ph.D. has attended advanced training with Antonio Paletta, MD, Robert Marshall, PhD, CCN, DACBN, Todd Ovokaitys, MD, Enrique Buron, PhD, Paul Drouin, MD/PhD, Susan Blackard, PhD/RN, Faith Nelson, PhD/RN, Bill Cunningham, WDH, Ginger Bowler, PhD, Linda Forbes, DC, LAc, OMD, Steven Small, MD, Adam Mandel, BFS,Eric Pearl, DC, and others. Kari Uselman, Ph.D. takes ongoing continuing education units (CEUs). Her wellness practice includes Quantum Biofeedback, Craniosacral Therapy, Semato-Emotional Release, Quantum Reflex Analysis, Vastu Bioenergetics, Cation Mudpacks, Sound Healing, Biological Decoding, Quantum Cold Wave Laser therapy, Complex Homeopathy, and Energy Healing.
I understand that Kari Uselman, PhD is a doctor of philosophy and education. She has over 20 years experience in education and wellness which she weaves into her practice. She takes ongoing seminars and courses in natural healing modalities through various institutions including the International Quantum University of Integrative Medicine, Premier Research Labs, White Dove Healing Arts, The Upledger Institute, Gematria, Quantum Clarity, and the Quantum Alliance.
SCOPE OF PRACTICE
I understand the intended purpose of biofeedback training and the other modalities offered by Kari support wellness and are for well-being, relaxation, trauma release, pain reduction, and musclere-education so I may learn to: 1) reduce my stress, 2) manage my pain, 3)improve the quality of my life, and 4) be well. I agree to advise Kari Uselman, Ph.D. anytime I feel any side effects, so steps may be taken to alleviate mydiscomfort.I further understand biofeedback and the other modalities Kari offers are not a substitute for effective standard medical,chiropractic or psychotherapy treatment or veterinary treatment for my pet. Kari Uselman, Ph.D. has advised me to continue ongoing medical treatment and therapies until otherwise advised by my psychotherapist, physician or medical practitioner. I understand it isimportant for me to stay in close communication with my physician. I further understandit is my responsibility to ask my medical doctor for permission to undergo biofeedbacktraining if I wear a pacemaker or have any medical condition that may be exacerbated byrelaxation.
I understand it is my responsibility to monitor the effects of my stress reduction protocols and the wellness modalities I choose. I will tell Kari Uselman, Ph.D. anytime Iexperience any discomfort during a session. I further understand thatresearch suggests that while most people gain considerable benefits from biofeedbacktraining, homeopathy and wellness support, some people may not gain any benefit. I have every expectation thatthe modalities I participate in will provide me some benefit, but I understand there is no guarantee that itwill.
CLIENT CONFIDENTIALITY
I understand my identity and any information about me, whether I share it with Kari Uselman, Ph.D.or she discovers it on her own, will be held in the strictest confidence, except when releasedby me or specifically required by law. I have the right to waive this confidentiality agreementin whole or part at any time. I also understand that I may give Kari Uselman, Ph.D. permission to contact my primary care practitioner or specialist with regard to the trainingprovided by her and the results I obtain. I have the right to withdraw this permission at anytime.
PAYMENT FOR SERVICES
I agree to pay Kari Uselman, Ph.D. for her services, based on her set fee schedule or otherwise negotiated by check, money order or cash for each session. In the event my check bounces, I agree to pay full restitution plus an additional$25 fee as a penalty. I I understand that if my appointment is cancelled with less than a 24 hours notice, or I do not show for my appointment, I will be charged 50% of my session rate the first time, 75% the second time, and charged 100% there after.
ARBITRATION
I agree that in the event Kari Uselman, Ph.D. and I are unable to reach an amicable solution to anyissues between us, we will appoint a mediator to help us settle our differences and we shall equally share the cost of this mediation.
CLIENT WARRANTY
By signing below, I acknowledge that I have read and understand this document, and havereceived acceptable answers to all of my questions about Kari’s services. I consent toreceive biofeedback training and the other services from Kari Uselman, Ph.D. I warrant I am not under duress at this timeand my consent is given voluntarily and without coercion. I further understand I maydiscontinue services at any time.
Name (Please print): (First, Middle, Last, Maiden)
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Date of Birth: ______Age: _____ City/State Born: ______Gender: ___ Male ___ Female ___
Address: (Street, City, State, ZIP)
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Home Phone: ______Cell Phone: ______Work Phone: ______
E-mail:______Current Medical Doctor: ______
Top3 Concerns:
1. ______2. ______3. ______
Date: ______Signature: ______