Name
*
First Name
Last Name
Email
*
Phone
*
Country
(###)
###
####
Do you have a diagnosis of bipolar I, bipolar II, or schizophrenia? If yes, please specify:
*
Do you have a history of mania or psychosis? If yes, please share a bit more with me.
*
Do you have a heart condition? If yes, please share more with me.
*
Are you pregnant or breastfeeding? If yes, please specify.
*
Psychedelic Clients: It is not recommended to work with psychedelics if you are on Lithium, tricyclic antidepressants (SSRI's & SNRI's are okay), MAOI's, or Tramadol.
Please share a bit about what your intention is for our work together:
*
Please tell me your top three day/time options for our weekly sessions. Be sure to include your time zone:
*
Is there anything else you would like me to know?
Cancellation Policy: 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!
*
Confidentiality: Everything shared in session will be kept confidential, including the fact that we ever worked together. 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 must also report any child abuse, elder abuse, or imminent danger I learn about.
*
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 PHONE CONVERSATIONS LONGER THAN FIVE MINUTES.
I have read and accept Axis mundi's terms and conditions (linked below):
*
Consent To Treatment: Your signature below indicates that you have read this Agreement and agree to its terms:
*
First Name
Last Name
Please send payment to confirm your booking. Thank you! I look forward to working with you soon.
