Informed Consent for a Child
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
In working with children, I work in collaboration with parents using a combination of play, conversation, and skilled touch. This approach helps to resolve problems associated with all kinds of stress, including post-traumatic stress. The goal is to support the child’s innate capacity for physical and emotional self-regulation and healing, which necessarily includes educating parents about this process. With young children, under 8, one or both parents are present and participating in sessions. With older children, we discuss and decide when to include parents and when to meet without parents. Sometimes siblings are also included in sessions, and sometimes I meet with parents alone. The expectation is that our attention to the child’s healthy functioning is in the context of the health of the family as a whole.
My work is not psychotherapy or medical treatment.
Payment for and timing of sessions
The cost is $220 for a 50-minute session.
Unless other arrangements have been made, payment should be made at the time of the appointment or in advance.
There is a $10 fee for returned checks.
I am not able to bill insurance companies.
My fee may increase at the beginning of each year.
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 who have made a commitment to a regular schedule of sessions can avoid paying for a cancellation by scheduling a make-up session in addition to their already scheduled sessions.
Please call me, do not email me, if you need to cancel or change an appointment.
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 with parents 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 is needed, we will schedule a phone or office appointment. Phone appointments will be charged at the same rate as office visits.
Drugs & Medication
Please let me know if your child is currently taking medication for the treatment of depression, anxiety, insomnia or any other psychological or neurological problem. Also, please inform me of any over-the counter medications, herbal or homeopathic medications that your child is using.
Contraindications
Because there are some medical conditions and symptoms that can become exacerbated or complicated by particular therapeutic touch techniques, it is very important that you inform me of your child’s current physical and medical condition and medical history, and that you update me of any changes in his/her condition.
Confidentiality
My work with your child is confidential, with a few exceptions. The exceptions are: If I believe your child may be a serious danger to self or others, or if I believe your child is being abused. Other than these situations, I will release information only with your written consent.
For teens: I will keep the personal content of your child’s session private and stay in communication with you, the parent, on an as needed basis
Coordination of Somatic Therapy with Other Therapies
If your child is currently pursuing therapy with a psychotherapist, counselor, or psychiatrist, please discuss with this therapist the plan for your child to also have somatic therapy. It is usually helpful for me to have consent for contact with any other therapist your child is working with, so that our work will be complementary. If you and I agree that it is useful for me to discuss your child’s case with another therapist or health care provider, a phone conference can be arranged. I will ask you to sign a consent form releasing me to discuss your child’s 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 authorize Lynne Anne Salman to provide somatic therapy for my child. I have been informed that the somatic therapy provided by Lynne Anne, including skilled touch, movement, play, and dialogue, is not psychotherapy or medical treatment.
I understand that Lynne Anne 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 of my child’s known medical conditions. I agree to keep Lynne updated as to any changes in my child’s health profile and understand that there shall be no liability on her part should I neglect to do so.
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.)