Now that you have booked your appointment, please tell me about yourself by completing the two forms below. After submitting the Health History, you will be re-directed back to this page to complete the Informed Consent form. If you would prefer to print and bring the forms with you to your session, request print version here.
Completing and submitting both the health inventory and informed consent forms in advance of your session will give us more time to devote to the session itself. Thank you for honoring both your time and mine. I look forward to meeting and working with you.
Informed Consent
(Please read carefully before completing the submission form is at the end of this page.)
Informed Consent Form
I understand that Ann Marie Humble will be teaching and demonstrating techniques in stress/pain management and muscular re-training. After consulting and agreeing on the best course of action to suit my individual needs, Ms. Humble will use and/or recommend one or more of the following modalities to assist in my progress to better health:
• Indigo biofeedback (Certified Biofeedback Practitioner)
• Emotional Freedom Technique (EFT) – Certified Tapping into Wealth Coach
• Personal/Lifestyle & Nutritional Coaching – Certified Wellness Coach
I understand my own health and wellness are my responsibility, and that I need to seek competent medical care if I have any medical conditions, disease or disorder. Therefore I agree to use the services of Ann Marie Humble to help me incorporate appropriate stress and/or pain management and lifestyle strategies.
I understand that if I have a health challenge, or think I may have a health challenge, Ann Marie Humble will help me manage my stress related to that problem and refer me to a licensed professional for further assistance upon my request.
BIOFEEDBACK (only):
The following warnings have been established in regard to biofeedback, based on risk analysis and must be implemented in my use of this device: Indigo biofeedback training is contraindicated (not recommended) for:
1. Clients with epilepsy or a history of epilepsy;
2. Clients who have a pacemaker;
3. Clients who suffer from electrical hyper reactivity;
4. Clients who have irritated, inflamed, red or broken skin;
5. Pregnant women;
6. Children under age three;
7. Clients who are under the influence of drugs or alcohol.
EFT – (Emotional Freedom Technique):
As part of my work with Integrated Lifestyle Solutions Ltd., I understand, I may learn about a clinically proven mind body technique known as Emotional Freedom Techniques (EFT), which is a type of energy release technique. I understand that EFT has been developed and refined since the early 1960’s and uses gentle pressure or tapping at meridian points (Chinese acupuncture points) but using gentle pressure or light tapping instead of needles and has been shown in many clinical environments to be helpful in reducing stress, anxiety and physical pain. The benefits and risks, are not fully known. The procedure involves acupressure (tapping with fingertips) on acupuncture points (acupoints) on the face, upper body and hands with the goal of stimulating designated meridian end points.
I understand that while many people experience benefits with EFT, others do not. There is no scientific explanation regarding why EFT works for some people and does not work for others.
CERTIFICATIONS AND ACCREDITATIONS:
I understand that Ann Marie Humble, (Integrated Lifestyle Solutions Ltd.) is not a licensed psychiatrist, psychologist, social worker, or mental health professional. She is not licensed or trained to diagnose any form of mental or physical illness, and she is also not licensed to prescribe or recommend any medication. I understand that I will not be receiving any form of mental health counseling from Ann Marie Humble (Integrated Lifestyle Solutions). I understand that Ann Marie will provide only services that are within the scope of her accreditations as a Certified Biofeedback Practitioner, Certified Tapping into Wealth Coach and Certified Wellness Coach.
CONFIDENTIALITY:
I understand my identity and any information about me, whether I share it with Ms. Humble or she discovers it on her own, will be held in the strictest confidence, except when released by me or specifically required by law. I have the right to waive this confidentiality agreement in whole or part at any time. I also understand I may give Ann-Marie Humble permission in writing to contact my primary practitioner or specialist with regard to the training provided by her and the results I obtain. I have the right to withdraw this permission at any time.
I understand that all sessions will be kept confidential unless I express an intention to harm myself or others.
FEES/CANCELLATIONS
I agree to pay Ann-Marie Humble her fees in amounts as posted in her office and on her website www.humblehealthwealth.com. Fees may be paid by cash, e-transfer, cheque or credit card for each session or series of sessions. In the event my payment is not honored by my financial institution, I understand that payment must be made in full, by means of cash, plus an additional $10.00 fee as a penalty.
I agree to give Ms. Humble at least 24 hours notice prior to any scheduled appointment if I must cancel or reschedule. Failure on my part to give timely notice of cancellation or rescheduling of an appointment will result in an additional $25 penalty to be assessed at my next session.
By checking this box, I understand and agree to the above terms.
