Lynne Anne Salman, C.S.T. ~ BodyMind-InnerWork 
1532 Solano Avenue, Albany, CA 94707 ~ (510) 524-7122

Certified Somatic Therapist: Association of Bodywork and Massage Professionals; member #123162
Somatic Experiencing Practitioner (SEP); certified by the Somatic Experiencing Trauma Institute
California Massage Therapy Council; certification #19206
City of Albany business license # 5972

In order to be as clear as possible about how I do business, I am providing the following information for you in writing. Please confirm your agreement at the end of the form and return it to me. Thank you.

Somatic Therapy

I use a combination of dialogue, guided sensory awareness and movement work, and skilled touch to work with clients. This method supports the body’s capacity for self-healing, increases emotional and mental clarity, and helps to resolve problems associated with all kinds of stress including post- traumatic stress. My work is not psychotherapy or medical treatment.

If touch is used in our work together, it will be used consciously, in agreement with treatment goals we have discussed together, non-sexually, and with your consent each time.

Payment for and timing of sessions

The cost of sessions is $220 for a 50-minute session. Fees may increase at the beginning of each year.

Unless other arrangements have been made, payment should be made at the time of the appointment or in advance. I am not able to bill insurance companies. There is a $10 fee for returned checks.

Cancellations & Missed Appointments

I require 48 hours cancellation notice. If you miss or cancel your appointment with less than 48 hours’ notice, you agree to pay for the missed appointment. Clients can schedule a make-up session instead of paying for a cancellation, if able to fit into my schedule within a week of the cancelled session. Phone sessions can be arranged if you are unable to come in.

Please call me, do not email me, if you need to cancel or change an appointment. An email is not a sufficient notice to be within my 48-hour cancellation policy.

Phone contact

My telephone number is 510-524-7122. I do my best to return client phone calls within 24 hours. I do not return calls on Friday evenings, Saturdays, and holidays.

Sometimes phone contact between sessions can be an important support to the work we are doing together. I am glad to have a brief check-in with you by phone as my schedule allows. If we decide together that a longer conversation would be helpful, a telephone session can be scheduled. Phone sessions will be charged at the same rate as regular sessions.

Drugs & Medication

Please let me know if you are currently taking medication for the treatment of pain, insomnia, depression, anxiety, or any psychological or neurological problem. Also, please inform me of the extent of your use of over-the counter medications, herbal or homeopathic medications, and alcohol or recreational drugs.

Contraindications

In some cases, symptoms can become exacerbated by somatic therapy and therapeutic touch techniques. It is, therefore, very important that you inform me of your current physical condition, any medical issues and your medical history, and keep me updated about any changes.

Confidentiality

Our work together is confidential, with a few exceptions. The exceptions are: If I believe you may be a serious danger to yourself or others; if I believe or suspect a child, an elder, or a disabled person is being abused. Other than these situations, I will release information only with your written consent.

Coordination of Somatic Therapy with Other Therapies

If you are currently pursuing therapy with a psychotherapist, counselor, or psychiatrist, please discuss with your therapist your plan to engage in somatic therapy with me as well. It is usually helpful for me to have your consent for contact with your therapist so that our work will be complementary. If you and I agree that it is useful for me to discuss your case with any health practitioner with whom you are working, a phone conference can be arranged. I will ask you to sign a consent form releasing me to discuss your case.

Chemical-Scent Free Policy

The office at 1532 Solano Ave is a chemical-scent free environment. This is necessary for the health and safety of my clients (many of whom are chemically sensitive) and also the clients of the other doctors and practitioners who work here and whose clients use the waiting area and rest rooms. Therefore, on the days of your appointments, please refrain from using scented products. This includes not only perfumes and colognes, but also soaps and shampoos, body lotions, deodorants, powders, other hair & body care products, and laundry products.

Limitations and Agreement

I have been informed that the somatic therapy provided by Lynne Anne, including dialogue, guided sensory awareness and movement work, and skilled touch is not psychotherapy or medical treatment.

I understand that Lynne does not perform manipulations or adjustments of the human skeletal structure, diagnose, prescribe, or provide any other service, procedure, or therapy which requires a license to practice (i.e. chiropractic, osteopathy, physical therapy, podiatry, orthopedics, psychotherapy or any other profession or branch of medicine).

Because some therapeutic touch techniques are contraindicated for certain medical conditions, I affirm that I have stated all my known medical conditions. I agree to keep Lynne updated as to any changes in my health profile and understand that there shall be no liability on her part should I neglect to do so.

I agree to tell Lynne if I am uncomfortable with any parts of this somatic therapy treatment. I have the right to refuse or terminate treatment at all times, or to refuse touch, somatic techniques, or any other interventions that she may propose or employ.

With my signature, I acknowledge that I have read and understand this entire informed consent document. I agree to the terms stated here and to pay the fee for sessions cancelled with less than 48 hours notice.

Please download this Agreement for your records and sign the following form by entering your name and clicking the Submit button. (Be sure to check the agreement box before submitting.)