Peer Coaching for Mental Health & Wellness Intake Form

The Teal Center for Therapeutic Bodywork, Ltd.
Mental Health & Wellness Coaching Intake & Consent Form
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Name*

First NameLast Name
Address:*

Street Address

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Email:*
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Phone Number:*
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Secondary Phone Number:
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Birth Date:*

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Age:*
Occupation:*
Preferred Pronouns: *
How did you hear about us?*
How did you hear about Peer Coaching for Mental Wellness?*
Emergency Contact:*

First NameLast Name
Emergency Contact Phone Number:*
Please enter a valid phone number.
Relationship to Emergency Contact:*
Would you like to receive email notifications on promotional discounts/newsletter?*

YesNo
Is this regarding you and/or someone you know (family, friend, coworker)?*
What brings you here today?*
What are your overall goals with your Peer Coaching sessions?*
What are you looking to walk away with or get out of your session for today?*
What are some of your expectations if any?*
What questions or concerns do you have?*
Is there anything else you think I should know?*
Client Agreement and Exclusion of Liabilities

*I understand that Anna Strasburger is not a licensed or clinical social worker, psychologist, physician, psychotherapist, marriage counselor, medical professional, medical doctor, medical provider, psychiatric nurse, nurse, interventionist, child-counselor, clergyman, massage therapist, social worker, Qualified Mental Health Professional as defined by the Virginia Department of Health Professions, counselor, crisis counselor, family-support partner, substance use counselor, addiction counselor, CSAC, mental health therapist, or trauma therapist.

Anna Strasburger is also not qualified to diagnose, perscribe or treat any ailment or condition; rather she will exclusively use a person-centered, peer coaching approach which may or may not aid in addressing concerns. I also understand that if I have any specific physical, mental or emotional problem(s), I should consult a licensed health professional for any prescribed course of treatment.

If you are unclear about anything offered or discussed during your sessions, it is your responsibility to ask for clarification. If you have questions regarding your pharmaceutical prescriptions, mental healthcare or medical advice, please consult with your doctor or therapist. Anna will provide services with reasonable care and skill but we make no other warranty, express or implied, with respect to those services. All other warranties are excluded to the maximum extent permitted by law. In no event will we be liable for any physical or mental injury, or any negative side effects or consequences, that may arise from sessions.

*I also understand though everything said is confidential, being that a Certified Peer Recovery Specialist (CPRS) is a state-mandated reporter, Anna will report any concerns if an individual is at risk to themselves or others; if there is any suspected abuse relating to minors, anyone with diminished capacity, and/or elders; active abuse; or threatened suicide/homicide per law.

I further understand that if the provider feels that anything discussed in sessions is beyond their scope or is inappropriate, they will make a recommendation for appropriate care and provide a resource. I also further understand, that if Anna feels that anything in the sessions has become inappropriate, she has the right to terminate the session and the client may be charged for full the session.

I have read and understood the above and agree with it.

Entering/typing and signing your name in the fields below constitutes signing the document, confirming the signer agrees to the terms and conditions stated.
Name*

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Date*

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CLIENT AGREEMENT

Please read and signwhere applicable
I, First Name Last Name ,give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.

I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk.
I also understand:
1. That massage therapy and/or acupuncture
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow; and
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
2. That the massage therapists and/or acupuncturists
- do not diagnose illness, disease or any other physical or mental disorder;
- do not prescribe medical treatment or pharmaceuticals; and
- do not perform any spinal manipulations.
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

If I need to reschedule due to illness or Covid exposure, I agree to contact the Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
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First NameLast Name
Signature:

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Date:*

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POLICIES

Welcome! Thank you for choosing The Teal Center!

Please read and initial each of the following:
blanks* Appointments missed, cancelled or rescheduled with less than 24 hours notice will be charged 50% of the session fee. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are sent 48 hours prior to the scheduled appointment.
blanks*The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to The Teal Center.
blanks* If you have a cold or other contagious illness, please call us before your so we can check with your therapist to see if it is appropriate for you to come in.
blanks* In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.
blanks* Tips are appreciated but never expected. If you wish to leave a gratuity, we ask that you do so in cash or by check made directly to your therapist. Gratuity is also made possible via the Venmo app for some therapists.
blanks* If you move or change numbers, it is your responsibility to inform us. This is important information so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.
blanks* The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.
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The Teal Center for Therapeutic Bodywork, Ltd.

Mental Health & Wellness Coaching Intake & Consent Form