Consent To Receive Biofeedback Training from Gila M. Zak, CBS
Please read this form, fill out portion at bottom, and click “Submit.”
I understand Gila M. Zak 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 prevent any nutritional medical or psychological disease, disorder or condition. I further understand 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 it is my responsibility to continue my medications and remain under the care of my primary physician.
I understand Gila M. Zak is a Certified Biofeedback Specialist and that she will train me with biofeedback for relaxation and muscle re-education so I can learn to reduce my stress, manage my pain and improve the quality of my life.
Scope of Biofeedback Practice
I understand the intended purpose of biofeedback training is for relaxation and muscle re-education so I may learn to: 1) reduce my stress, 2) manage my pain, and/or 3) improve the quality of my life. I understand 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 biofeedback training sessions. Other potentially harmful side effects not yet reported may occur. I agree to advise Gila any time I feel any side effects so corrective steps may be taken to alleviate my discomfort.
I further understand biofeedback is not a substitute for effective standard medical, chiropractic or psychotherapy treatment or veterinary treatment for my pet. Gila has advised me to continue ongoing medical treatment and therapies until otherwise advised by my psychotherapist, physician or medical practitioner. I understand it is important for me to stay in close communication with my physician. I further understand it is my responsibility to ask my medical doctor for permission to undergo biofeedback training if I wear a pacemaker or have any medical condition that may be exacerbated by relaxation.
I understand it is my responsibility to monitor the effects of biofeedback training and to continue the training as long as it is beneficial to me. I will tell Gila any time I experience any discomfort during biofeedback training. I further understand that research suggests that while most people gain considerable benefits from biofeedback training, some people may not gain any benefit. I have every expectation that biofeedback will provide me some benefit, but I understand there is no guarantee that it will.
I understand my identity and any information about me, whether I share it with Gila 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 Gila 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 Gila M. Zak $80.00 per hour or $120 per one and ½ hour by check, money order, credit card or cash for each biofeedback session. In the event my check bounces, I agree to pay full restitution plus an additional $25.00 fee as a penalty
I agree that in the event Gila and I are unable to reach an amicable solution to any issues between us, we both agree to accept the decision of the attorney arbitrator of the Natural Therapies Arbitration Council as the final settlement of our differences. I understand this service is provided through the Biofeedback Association of North America (800-985-0819) at no cost to me. I further understand that if the arbitrator finds against me, I will not be required to pay a penalty above whatever amount the arbitrator finds equitable.
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 Gila M. Zak. I warrant I am not under duress at this time and my consent is given voluntarily and without coercion. I further understand I may discontinue biofeedback training at any time and that I may refuse to participate in any particular or specific biofeedback training without penalty.