Tracy Faulkner

Biofeedback Specialist
Client Forms
Informed Consent

I understand that Washington State issues licenses to health care professionals. This license authorizes them to analyze, assess, diagnose, evaluate, examine and investigate their patients to determine what's wrong with them. This license also authorizes them to advise, caution, counsel, guide, prescribe, recommend and suggest cures, drugs, interventions, remedies and treatments to address what's wrong with them. No other person in Washington State may do any of these things without a license including Tracy Faulkner.

I understand it is illegal in Washington State to ask any non-licensed person, including Tracy Faulkner, to diagnose, treat, counsel, cure or attempt to cure me of anything.

I understand Tracy Faulkner is a (certification) qualified to help me make more informed decisions about my own life and health care. I also understand biofeedback is intended to help me relax so I can manage my stress and pain and improve the quality of my life. I further understand she will teach me some basic empowering Coaching techniques to help me improve the quality of my life.

I understand that I am responsible for my own health, healing and well being. I also understand I have the ability to heal myself. I further understand biofeedback is not a substitute for adequate medical care and I intend to remain under the care of my primary healthcare provider.

I have read and understand the Policies and Procedures Tracy Faulkner has published and shared with me. I agree to abide by these Policies and Procedures.

I understand Tracy Faulkner will keep all information she learns about me completely confidential unless I release her in writing or as required by law. I further understand Tracy Faulkner will not acknowledge my presence or discuss anything with me publicly unless I initiate the conversation and the topics of discussion.

I understand that if I have, or if I think I have a medical concern, condition, disease, disorder, issue or symptoms, Tracy Faulkner will help me reduce any related stress and refer me to a licensed chiropractic, medical or osteopathic physician for further assistance.

I also understand if I have, or if I think I have a psychological or emotional concern, condition, disease, disorder, issue or symptoms, Tracy Faulkner will help me reduce any related stress and refer me to a licensed counselor, psychologist or psychiatrist for further assistance.

I understand my own health and wellness is my responsibility. Therefore I agree to use the services of Tracy Faulkner to help me learn how to manage stress and pain.

I understand Tracy Faulkner will keep all information she learns about me completely confidential unless I release her in writing or as required by law. I further understand Tracy Faulkner will not acknowledge my presence or discuss anything with me publicly unless I initiate the conversation and the topics of discussion.

I acknowledge that I have read and understand this form. I agree to allow Tracy Faulkner to help me learn to heal myself using through her coaching and biofeedback.

   
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*The "Informed Consent" form will need to be provided at time of consultation.  Please read, fill-out and print this page.

 

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