Practitioner Disclosure and Client Consent Form
Welcome to my practice. In September of 2002, the California legislature passed Senate Bill 577, which requires all non-licensed health care practitioners in the state of California to disclose information to their clients about their practice. This bill, which took effect January 1, 2003, is really a consumer protection bill - designed to ensure that consumers of non-licensed health care practices have sufficient information about the practitioner they're working with, before entering into a working agreement. (For more information about the bill, see www.flowersociety.org/HealthFreedom.htm .)
In accordance, with this bill, I'm required to provide you with this written disclosure statement, and to keep a copy of this statement with your signature. Please read it thoroughly and let me know if you have any questions or concerns.
Non-licensed - I am a practitioner of classical homeopathy. I am not a licensed physician, nor are homeopathic services licensed by the state of California.
Description of Modality - Homeopathy is based on the law of similars which states that all substances in nature have a symptom profile that they illicit in a healthy individual - and that when a particular substance is given in its diluted form (that is, a homeopathic preparation of the substance), it stimulates healing of the same set of symptoms that the substance in its physical form causes.
For example, homeopathic coffee might be used to stimulate the healing of insomnia. Homeopathic onion might be used to stimulate the healing of watery eyes and other allergy symptoms. (For more details on homeopathy, see the links What is Homeopathy, Introduction to Homeopathy, and Homeopathic Terms.)
Description of Profession - A homeopath is a professional that understands the symptom pictures of homeopathic remedies, that is trained on how to interview a client to illicit a symptom picture, and that can analyze a case in order to select the remedy or remedies which most closely matches the client's symptom picture. Homeopaths are not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies.
What to Expect from Remedies - Homeopathic remedies are safe, have no known side effects, and can be used safely and effectively with conventional medications. However, homeopathic remedies cannot be used in place of conventional medications. Also, homeopathic remedies can sometimes cause a retrace of old symptoms, in which symptoms become temporarily heightened as part of the healing process. (For more information on this topic, see Before You Take a Remedy - What to Expect from Homeopathic Treatment. Also see, Frequently Asked Questions about What to Expect.)
Description of Services - During a consultation, I interview clients in order to get a clear picture of physical and emotional symptoms, and then use muscle testing to select the remedy or remedies which most closely matches the presenting picture. In addition, I use muscle response testing to select the most optimal potency and dosage. (For a more detailed description of the services I provide, please see What exactly do you do in your practice?).
Training and Experience - I have been practicing homeopathy full time for twenty four years. I received an MA in Homeopathy from the American University of Complimentary Medicine. This was a four year part time training program that included homeopathic philosophy, principles of classical homeopathy, materia medica, case taking, and case management. I am also certified in classical homeopathy by the CHC (Council for Homeopathic Certification). (For a more detailed description of my training and experience, please see What type of training and experience do you have?).
In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will receive a copy. I will keep the original in my records for at least three years.
My method of treatment, homeopathy, is alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California's Business and Professions Code, I can offer you these services, subject to requirements and restrictions of Senate Bill 577. (See www.flowersociety.org/HealthFreedom.htm for more details on these requirements and restrictions.)
If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor that you are receiving homeopathic treatment.
Acknowledgement and Consent to Receive Services
I have read and understand the above disclosure about the homeopathic treatment offered by Laurie Monteleone and Laurie's training and education. I have discussed with Laurie the nature of the services to be provided. I understand that she is not a licensed physician and that her services are not licensed by the state of California. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Laurie Monteleone, and agree to be personally responsible for the fees in connection with the services she provides me.
Signed: ___________________________ Date: _________________________
Indicate capacity to sign if other than client ________________________