SUZANNE CLEGG RDN, LAc Client Informed Consent and Disclosure Statement For Office Sessions Thank you for your interest in working with me as a client. I am providing you with the following information so you can make an informed choice about your decision to engage my services. Please read this information carefully and let me know if there is any part you do not understand. Our work together will include a shared understanding of what you hope to accomplish and agreements for supporting those outcomes. Although I will use my skills and abilities my work with you is only a resource. As an intentional and conscious participant in your healing journey, you will ultimately take all responsibility for your health and well-being. SERVICES OFFERED THEORETICAL APPROACHES As part of my practice, I offer traditional acupuncture and oriental medicine, nutritional counseling, and several innovative energy-based healing techniques which you have the option of using individually or collectively as part of our work together. I also offer several Alternative Cancer Therapy Packages which incorporate my Octave Holistic Healing Approach. Below are a list and brief description of the various healing methods I use in my practice. Please feel free to ask me for further resources or references regarding any of the methods I use. Acupuncture and Oriental Medicine Acupuncture treatment involves the evaluation of a client according to the theories of Chinese medicine (yin, yang; hot, cold; deficient, excess). According to Oriental Medical Theory, the body has 12 main meridians through which energy or Qi flows. Excess, deficient or obstructed Qi causes pain or dysfunction. Acupuncture treatment balances and moves the energy using the above-mentioned techniques to effect change. Acupuncture has the effect to normalize physiological functions, to modify the perception of pain, and to treat certain
diseases and dysfunctions of the body. This therapy is indicated for functional disorders of the musculoskeletal, respiratory, reproductive, gastrointestinal and neurological system or even trauma. Treatment could involve needles, moxibustion, heat lamp, cupping, guasha, and or massage. Some recommendations regarding diet and lifestyle may be suggested. Octave Healing Method One of the components of my Octave Holistic Healing Approach is the Octave Healing Method which is an alternative healing technique I developed based on the Bengston Energy Healing Method created by William Bengston, PhD. (the Method ). The Method engages energy fields and systems natural to each person and the Universe. The premise is the Method creates changes in the energy or spiritual (non-physical) aspects of the client which then can manifest in the physical body. I often receive images that may have clinical relevance which can be described as channeling. When using the Method, I am connecting to the energy or spiritual bodies of the client while using a laying on of hands approach. You understand there is a distinction between healing using the Method and the practice of medicine or any other licensed health care practice. Please refer to the Octave Healing Method Information Sheet for a more in depth description of the Method. Dr. Bengston has conducted substantial published research with animal populations using the Bengston Energy Healing Method indicating the approach upon which the Method is based as effective. Although the Method appears to have promising physical, mental, and spiritual health benefits for humans, the Method has yet to be fully researched by the Western academic, medical, and psychological communities and therefore, is considered experimental for human application. Although I am a New York State licensed Acupuncturist, a National Board Certified Acupuncturist, a Registered Dietitian, certified Acutonics Sound Healer and Instructor, I m not a licensed medical doctor or psychologist. You understand if you voluntary choose to use the Method as part of your treatment plan, then by signing this document you acknowledge the Method would be considered experimental and alternative or complementary to the healing arts that are licensed in the United States. Dietary, Herbal and Whole Food Nutritional Counseling As a Registered Dietitian I offer dietary, herbal and whole food counseling from a variety of cultural perspectives (Western scientific, Oriental, Anthroposophic, etc.) to support the healing process. I also incorporate Essential Oils if indicated, which are derived from plant oils and applied topically.
Acutonics Sound Healing System The Acutonics Healing System is an energy-based non-invasive treatment that is similar to acupuncture ( Acutonics ). Precision calibrated tuning forks are applied to specific acupuncture and acupressure points to access the body s Meridian and Chakra energy systems. All the Acutonics tuning forks represent a natural harmonic series based on the orbital properties of the Earth, Moon, Sun, Planets and other celestial bodies. Their rich resonance and vibration connects with and supports the body s natural frequencies to bring us into alignment with the cycles and rhythms of the Cosmos known since antiquity as the Music of the Spheres. The tuning fork is struck on an Acutonics acuvator then placed on the body or held near the ears. The sound waves of the forks vibrate and travel deeply into the body along these energy pathways, affecting human physiology and reaching places not easily accessed by traditional medicine. Applying the forks stimulates and balances the body s physical and subtle energy field to promote healing and inner harmony. Listening to the forks speaks to us deeply by connecting with our vestibular system, within the inner ear canal, and accessing our sense of motion, balance, space, memory and healing. You understand if you voluntary choose to use Acutonics as part of your treatment plan, then by signing this document that you acknowledge Acutonics would be considered experimental and alternative or complementary to the healing arts that are licensed in the United States. OUTCOME EXPECTATIONS Please note that it is impossible to guarantee any specific results regarding your goals using any of the healing methods described above and we don t know how you will personally respond to any of the healing methods you may choose to use and/or whether any of the above mentioned healing methods will help you achieve the goals we establish in our work together. However, we will work together to achieve the best possible results for you. RISKS AND BENEFITS Acupuncture and Oriental Medicine Acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, soreness, numbness or tingling near the needling sites that may last a few days and dizziness or fainting. Bruising is a common side effect of cupping and burns and/or scarring are a potential risk of moxibustion and cupping. Infection is another possible risk,
although my clinic uses sterile disposable needles and maintains a clean and safe environment. You understand that while this document describes the major risks of treatment, other side effects and risks may occur. Dietary, Herbal and Whole Food Nutritional Counseling The historical record and modern research indicate that the herbs most often used for health care have an exceptional safety record. However, adverse events can occur, including toxicity using any active substance. In addition, there are potential herb-drug interactions. Please refer to the Informed Consent and Disclosure Statement for Herbal Medicine attached hereto and incorporated herein by reference for further information. Octave Healing Method and Acutonics Sound Healing System The Method and Acutonics are relatively new healing approaches and the extent of their effectiveness, as well as their risks and benefits, are not fully known. Please be advised that in using the Method and/or Acutonics emotional and/or physical sensations or additional unresolved memories may surface which could be perceived as negative side effects. It is possible to experience some emotional distress and/or physical sensations related to prior life experiences. The clinical reports from energy therapies such as the Method and Acutonics show no additional side-effects when used appropriately. Emotions and/or physical sensations may continue to arise after a session and you are encouraged to discuss such emotions with me. If advisable, I will refer you to an appropriate professional health care provider. You understand and agree that you do not expect me to be able to anticipate and explain all the risks and complications, and you wish to rely on me to exercise judgment during the course of our sessions which I feel at the time, based upon the facts then known, and is in your best interest.
OTHER IMPORTANT INFORMATION You have been advised that the Method and Acutonics are not intended to diagnose, treat, cure, or prevent any disease or psychological disorder. However, when using the Method, I set a healing intention in relationship to a particular issue or problem presented by my client. If you have purchased one of my Alternative Cancer Therapy Packages which provides a number of techniques and healing approaches I identify as the Octave Holistic Healing Approach (the Packages ) you understand the Packages are solely designed to support your body s own ability to heal and find balance. The Packages are not a cancer treatment as defined by Western medicine but instead a group of adjunct healing techniques and complementary approaches to support the production of healthy cells and to foster wellbeing. By using the Method focusing on this healing intention, it s possible for the client to experience changes in his/her energy or spiritual aspects which then can manifest in the physical body. If appropriate, I may use the Method to charge cotton, water or oil with a healing intention for you. Please refer to the Instructions re: Charging Document attached hereto and made part of this Client Informed Consent & Disclosure Statement. Further you have been advised that using the Method and/or Acutonics, whichever is applicable, does not replace health care professionals. You agree to consult with your health care provider for any specific health care problems. As a licensed acupuncturist in New York State, I am an independent provider of acupuncture. There is no need for a physician s referral. However, according to New York State law, it is required that if you are seeking acupuncture treatment from me that I advise you to consult with a physician regarding the condition or conditions for which you are seeking acupuncture treatment. Acupuncture and its related therapies is not a substitute for consultation with your medical doctor. In addition, you understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing any of your health care professionals or using prescribed medication, if any, without consulting with your health care professional, even if after a session it appears and indicates that such medication or treatment is unnecessary. You agree to take full responsibility for your self-care in the, emotional, mental, physical, and spiritual dimensions of your life. If during or after any session you experience any distressing reactions, please bring this to my attention, and if appropriate, I can refer you to an appropriate licensed health care professional for further assistance. If you ever have any concerns about the nature of your sessions, please feel free to discuss them with me.
TRAINING AND EDUCATION I ve been a licensed acupuncturist in New York since 1992 and am a National Board Certified Acupuncturist having completed my training at the Tri-State Institute of Traditional Chinese Acupuncture. I m also a certified Acutonics sound therapist and instructor, Bengston Energy Healing Method practitioner, and have developed skills as a medical intuitive. I m a Chinese herbalist, Western herbalist and also a Registered Dietitian. I have over 4 years of graduate studies in neurophysiology, studied and trained with numerous healers, and bring 30 years of clinical experience to my clients. ACKNOWLEDGMENT AND CONSENT TO RECEIVE SERVICES By signing this document, you acknowledge you have been informed about the risks and benefits and agree that I have disclosed to you sufficient information to enable you to decide to undergo or forgo engaging my services and using any of the healing methods I offer, whichever is applicable, and other services/products I offer. Further, by signing this document, if applicable, you affirm you have been advised by me, to consult with a physician regarding the condition or conditions for which you are seeking acupuncture treatment for. You understand that you are freely choosing to take advantage of my services and would otherwise have the option of using conventional services exclusively, provided by another practitioner of your choosing. You understand that your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. Further you understand the Method and Acutonics are new healing approaches and the extent of their effectiveness, as well as their risks and benefits are not fully known. Therefore, you agree to assume and accept full responsibility for any and all risks associated with using the Method and/or Acutonics, whichever is applicable. You represent that you re competent and able to understand the nature and consequences of the proposed sessions using any of the healing methods and services I offer. You acknowledge that we have discussed and you understand and agree to my standard Office Policies and Procedures regarding fees, cancellation policy, confidentiality, and miscellaneous items which is attached hereto and incorporated herein by reference. Further, if applicable you acknowledge that we have discussed and you understand and agree to the Client Informed Consent and Disclosure Statement for Herbal Medicine attached hereto. You intend this consent form to cover the
entire course of treatment for your present condition and for any future condition(s) for which you seek acupuncture treatment or any of the other healing methods I offer. You have read and understand the above disclosure about the services offered by me and my training and education. You have discussed with me the nature of the services to be provided and you understand although I am a New York State licensed Acupuncturist, a National Board Certified Acupuncturist, a Registered Dietitian, certified Acutonics Sound Healer and Instructor, a certified Bengston Energy Healting Method practitioner, I m not a licensed medical doctor or psychologist and that my services using the Method and/or Acutonics are not licensed by the State of New York. You understand it is your responsibility to maintain a relationship for yourself with an appropriate professional health care provider. You have consented to use the services offered by me and agree to be personally responsible for the fees related to the services. By signing in the space provided below, you knowingly, voluntarily, and intelligently assume these risks and agree to release, indemnify, hold harmless and defend Spirit Gate Acupuncture, PC, its owners, officers, agents, consultants, assistants, and employees from and against any and all claims of whatsoever kind or nature, which you, or your representatives, may have for any loss, damage, or injury arising out of or in connection with your sessions. Please sign both copies of this Client Informed Consent and Disclosure Statement to acknowledge that you have read and understand this document in its entirety. A copy for your records will be returned to you. I will retain a copy for my confidential records. Client's name Are you pregnant? Client's (or guardian's) signature: Date Signature of treating acupuncturist (Suzanne Clegg, L.Ac)
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Kindly furnish my insurance company or their representatives with all information you may have regarding my condition while under your treatment or observation, including the history obtained, x-ray and physical findings, diagnosis and prognosis. Name: Date: Signature: 2010 Midge Murphy. All rights reserved. Any unauthorized use of this Client Informed Consent & Disclosure Statement is prohibited by federal law. No part of this document may be reproduced or transmitted in any form or by any means, including photocopying, for public and/or private use without permission in writing from Midge Murphy. Octave Holistic Healing Approach and Octave Healing Method are trademarks of Spirit Gate Acupuncture, PC and may only be used with permission. Bengston Energy Healing Method is a trademark of L & B Consulting, Inc being used with permission.