Name
First Name
Last Name
Email
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Phone
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Country
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Which type of session would you like to schedule?
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Do you have a diagnosis of bipolar I, bipolar II, or schizophrenia? If yes, please specify:
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5. Do you have a history of mania or psychosis? If yes, please share more with me.
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6. Do you have a heart condition? If yes, please share more with me.
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7. Are you pregnant or breastfeeding? If yes, please specify.
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Please share more about your mental health history with me, so that I can ensure the greatest amount of support in our work together.
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What would you would like to focus on in our work together?
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What are the best days/times for us to meet? Please include your time zone:
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EMERGENCIES: I AM NOT AVAILABLE 24/7 AND AM THEREFORE UNABLE TO RESPOND TO EMERGENCIES OR URGENT MATTERS. TELEPHONE CONSULTATIONS BETWEEN SESSIONS ARE AVAILABLE WHEN NEEDED. THERE is a PRORATED FEE FOR ANY PHONE CONVERSATIONS LONGER THAN FIVE MINUTES.
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CONFIDENTIALITY: EVERYTHING SHARED IN SESSION WILL BE KEPT CONFIDENTIAL, HOWEVER, IF YOU ARE INVOLVED IN IN A LIFE-THREATENING EMERGENCY I WILL SHARE INFORMATION IF I BELIEVE IT WILL BE HELPFUL TO YOU. I will ALSO REPORT ANY CHILD ABUSE, ELDER ABUSE, OR IMMINENT DANGER I LEARN ABOUT.
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If you need to cancel or reschedule your session, please provide at least 24 hours notice. If you miss your session without canceling, or cancel with less than 24 hours notice, you will be responsible for the cost of the session. Thank you!
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I practice psycho-spiritual coaching and healing. Our relationship is a practitioner-client relationship and not a therapist-patient relationship.
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Do you have any questions for me?
I have read and accept Axis mundi's terms and conditions (linked below):
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CONSENT TO TREATMENT: YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS:
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First Name
Last Name
Please send session payment to confirm your booking. Thank you! I look forward to working with you soon!
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