Intake Forms

DISCLAIMER

I understand that Germaine Parra is not licensed as a chiropractor, counselor, medical doctor, psychologist or psychotherapist, and does not portray herself as such. I understand, she will not diagnose, evaluate, treat, cure, mitigate or present any nutritional, medical or psychological disease, disorder or condition. I further understand that she will not advise, recommend, suggest or counsel me on any medical, dietary, emotional or psychological treatment, condition, disorder or disease of any kind. I further understand that it is my responsibility to continue my medications and remain under the care of my primary physician.

CREDENTIALS

I understand that Germaine Parra is a BaZi biofeedback practitioner who will “train” me with biofeedback frequency transmission for relaxation and muscle re-education to encourage a healthier bio-terrain that supports stress reduction, pain management, and improvement to quality of my life. I further understand that she will refer me to qualified experts for any other concerns that I have about my health and wellness.

SCOPE OF BAZI BIOFEEDBACK PRACTICE

I understand that the intended purpose of biofeedback training is for relaxation and muscle re-education so that I may learn to: 1) reduce my stress, 2) manage my pain, and/or 3) improve the quality of my life. I understand that biofeedback training is generally considered safe, but it is possible that biofeedback may exacerbate some emotional problems or I may become drowsy, at least temporarily, during the BaZi biofeedback training sessions. Other potentially harmful side effects not yet reported may occur. I agree to advise Germaine Parra anytime that I feel any side effects, so corrective steps may be exacerbated by relaxation.
I understand that it is my responsibility to monitor the effects of BaZi biofeedback training and to continue the training as long as it is beneficial to me. I will tell Germaine Parra anytime that I experience any discomfort during biofeedback training. I further understand that research suggests that while most people gain considerable benefits from BaZi biofeedback training, some people may not gain any benefit. I have every expectation that BaZi biofeedback will provide me some benefit, but I understand that there is no guarantee that it will.

CLIENT CONFIDENTIALITY

I understand that my identity and any information about me, whether I share it with Germaine Parra, 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 that I may give Germaine Parra permission in writing to contact my primary care 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.

PAYMENT FOR SERVICES

I agree to pay Germaine Parra by check, credit card, cash, PayPal, or other agreed upon payment method for each BaZi biofeedback session. In the event that my check bounces, I agree to pay full restitution plus an additional $15 penalty fee.
I also understand that I am required to give 24 hours advance notice to cancel, and will be charged for the session if advance cancellation notice is not given.

CLIENT WARRANTY

By signing below, I acknowledge that I have read and understand this document, and have received acceptable answers to all of my questions about biofeedback services. I consent to receive biofeedback training from Germaine Parra. I warrant that I am not under duress at this time and my consent is given voluntarily and without coercion. I further understand that I may discontinue biofeedback training at any time and that I may refuse to participate in any particular or specific biofeedback training without penalty.