Consent for Treatment and Client Privileges of
Enlightened Circles, LLC
As a client of Enlightened Circles, LLC you obtain the right to proper care and protection of your complementary and alternative health care. There is no license available or required for services provided in accordance with NM HB664. Jessica Sánchez-Romo, MD of Enlightened Circles, LLC is an unlicensed health care practitioner of alternative and complementary health care which is to be administered in addition to health care services provided by licensed practitioners. Please read everything carefully and if you have any questions regarding your rights, please ask Jessica.
Confidentiality and Release of Information: I acknowledge and understand that the information concerning my treatments and interactions with Enlightened Circles, LLC will be kept confidential and my rights to privacy will be protected. I understand that my information is not to be disclosed without my written permission, or that of a legal guardian with the EXCEPTIONS of particular situations such as:
If I threaten to injure/ cause harm to myself or others.
When there are legal requirements to report information regarding items such as abuse, neglect, molestation, exploitation of a minor, incapacitation, in the case of a court order or any other legally enforceable reason.
I acknowledge and understand my right to:
A standard of professional care tailored to my needs.
Refuse a recommendation, treatment or health and wellness plan.
Be the decision maker of my care prior, during and after treatments.
Review my assessment of treatments and records.
Continuation of care unless formal advisement has been given.
Be advised of other options or choices outside of Enlightened Circles.
All communications and records to be kept confidential.
Consent to Treatment: I understand that Jessica Sánchez-Romo or any therapist of Enlightened Circles, LLC, will explain my tailored treatment to be provided along with the possible benefits, risks and other items available. Furthermore, I understand that there is a professional standard of care that will be provided and although improvement for treated items is expected, it is not guaranteed. I also acknowledge that I have an active part in my positive healing and transformation and my commitment must start within myself. I understand that each person is unique and results are different for each person who seeks treatment. I agree to be a co-creator in my transformation and healing process. Furthermore, I acknowledge that I may choose to dismiss myself as a client of Enlightened Circles, LLC. I also understand I may be dismissed as a client of Enlightened Circles, LLC and refused treatment with just cause or reason.
Late arrival and Cancellation Policies: Enlightened Circles understands that unanticipated events may occasionally happen and would like to be effective and fair to all clients. I understand that any exception to the following policies are at the discretion of the therapist. I understand that promptness is expected for all appointments and that arriving late, in person or online, will limit my treatment time which may lessen the effectiveness and my experience. In the event of late arrival, the Enlightened Circles Therapist may end the scheduled session on time due to other commitments of the therapist and other clients. Fees will be maintained per the schedule and the full value of my treatment will be charged. I understand cancelation of any appointment must be received at least 24 hours in advance or I will be charged the full amount. All fees are non-refundable. If I miss an appointment either because I forget or consciously choose to forgo my appointment I will be considered a no-show and will be charged 100% for my missed appointment. Any appointment I make within 24 hours is non-cancellable and non-refundable. Cancelation of private parties require one week notice or they will be charged in full. I may be asked to provide credit card information in order to guarantee my appointment.
Notice of E-mail and electronic communication such as text messages or other: I understand that there are risks regarding e-mail/electronic communication such as some of the following examples:
E-mails/electronic communication may be intercepted by someone who is not the intended recipient.
Unauthorized recipients storing or printing information.
The accidental transport of computer virus and other malicious software.
E-mails/electronic communications are easily, and sometimes accidentally, forwarded to unintended recipients.
Receipt of emails/electronic communications are sometimes not noticed and not responded to in a timely manner.
Emails/electronic communications should never be used to communicate emergency, urgent or other time sensitive information.
I understand that Enlightened Circles, LLC is doing all they can to protect my private information, which is the reason I am being informed of some of the possible risks associated with E-mail and electronic communication. I also understand that I may opt out of participating in e-mails and electronic communication by not providing my email address below or with written denial.
Notice to Enlightened Circles, LLC of Medical or Other Concerns: I understand I have the right as well as responsibility to communicate openly with my therapist of Enlightened Circles and notify them with complete and accurate health information and about any special health considerations such as but not limited to high blood pressure, diabetes, allergies, physical ailments or disabilities requiring special assistance, pregnancy or any other health condition or concern. I have the obligation to alert my therapist of any discomfort I may experience immediately.
This is your time to delight in this experience to the fullest, so if it is the room temperature, volume of music or other items we ask you to please communicate with us responsibly and share your preferences so Enlightened Circles may attempt to make this the best experience possible in person or online. In order to assist this relaxing environment, we request your cell phones be silenced with no vibrations or turned off during your session.
Contact information, Health History and Consent Signatures:
I have been informed of my rights as a client of Enlightened Circles, LLC, and the policies. I hereby give my written consent for assessment and treatment.
Client Name (First, Last): ____________________________________________________________
Age: ______ Birthdate: ___________ M/F: _______ Marital Status: __________
Phone Numbers: (Please include area code or country code that applies.)
Home: ____________________ Cell: ___________________ Other: ____________________
Emergency Contact Info:
Skype ID: _____________________________________
Referred By: __________________________________
Health History or Spiritual/Emotional History you would like to share and work on: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Client Signature (Parent or Guardian) Date
Printed Name (Parent or Guardian) Date