Terms of service
Disclosure and Consent Form required to be reviewed and signed prior to your session with me:
As of January 1 st , 2003, alternative health care practitioners such as myself, Holly Strother, can lawfully practice in the state of California without violating the state Medical Practice Act. Under Sections 2053.5 and 2053.6 of California’s Business and Professionals Code, I can offer you these services contingent upon this disclosure to you and after obtaining from you written acknowledgement that you have received this information. I will retain a copy of this disclosure for at least three years.
Disclosure: I am NOT allowed to perform the following actions: (1) Conduct surgery or any other procedure that punctures the skin or harmfully invades the body (2) Administer or prescribe X-ray radiation (3) Prescribe or administer legend drugs or controlled substances (4) Recommend the discontinuance of legend drugs or controlled substances prescribed by an appropriately licensed practitioner (5) Willfully diagnose and treat a physical or mental condition of any person under circumstances or conditions that cause or create a risk of great bodily harm, serious physical or mental illness, or death (6) Set fractures (7) Treat lacerations or abrasions through electrotherapy (8) Hold out, state, indicate, advertise, or imply to a client or prospective client that I am a physician, a surgeon, or a physician and surgeon.
Services: The service I provide is not directly licensed by the State of California. My work is alternative or complimentary to healing arts services licensed by the State of California. The modality I offer is Biodynamic Cranial Touch. This approach orients to health as wholeness and the inherent healing power of your own body.
Qualifications: 18 years of experience as a Registered Nurse providing bedside care; 10 years meditation practice; certified Energy Medicine Practitioner (500+ hours), Biodynamic Cranial Touch Practitioner (200+ hours), Peirsan Craniosacral Academy (300 hours), Yoga Teacher Training (200+ hours). Please discuss with me any questions or concerns you have about my services and qualifications before our session begins.
ACKNOWLEDGEMENT OF DISCLOSURE AND CONSENT TO RECEIVE SERVICES:
I have read and understand the above disclosure. I have discussed with Holly the nature of her services and I have consented to receive the services she offers. I understand these services are not diagnostic nor billable by insurance and I agree to be personally responsible for the fee of the session in connection with the services she provides me.
Please Print Name:____________________ Date: _________________
Signature: ______________________ Phone: __________________
Email: _______________________