Release Forms

This is an Informed Consent Form required for all services. Informed Consent Form I understand that: o The services that Deborah Lundquist provides are alternative modalities o These services are not considered a replacement or substitute for medical care or therapy. o In addition to these services provided by Deborah Lundquist, she recommends that I seek appropriate medical care and therapy at all times, and o It is my responsibility to ascertain my need for medical care or therapy. I understand that Deborah Lundquist is neither a licensed physician nor medical professional nor a licensed psychologist or mental health professional and that she neither diagnoses, nor prescribes for, nor treats, cures or heals any physical, emotional, psychological or mental conditions and illnesses. I accept responsibility for my physical, emotional, psychological, mental, and spiritual well-being and for my reactions and responses to any information presented in the services provided by Deborah Lundquist. I acknowledge that information obtained through these services (including but not limited to hypnotherapy sessions or trainings) are considered intuitive advice and simply that and is not intended to constitute professional, legal, medical, emotional, psychological, instructional, real estate or financial advice. I further acknowledge that actions taken based on the information obtained through these services are my responsibility. I understand that Deborah Lundquist makes no guarantees, expressed or implied, with respect to accuracy, relevancy, or quality of these services. Deborah Lundquist hereby disclaims any liability to any person or entity for any loss or damages (including, without limitation, physical, mental, special, indirect, incidental or consequential) based on any information, suggestion or advice provided during these services. I agree that the services provided by Deborah Lundquist, whether purchased for self or received as a gift, are subject to my own interpretation. I understand that these services are offered only to those persons who are of legal age (determined to be 18 years of age) at the time of the booking of the session. If I am not of legal age, I will provide written consent from a parent or legal guardian in order for these services to be scheduled. I further acknowledge and understand that any conversation had and information provided during these services shall be considered confidential and shall not be disclosed except as required by law. I acknowledge that I have voluntarily agreed to participate in the services offered by Deborah Lundquist and request Deborah Lundquist to perform these services. I confirm in this Informed Consent the conditions of my participation in these services to be performed by Deborah Lundquist, am aware that this Informed Consent contains a release of liability and a contract between myself and Deborah Lundquist, and sign this Informed Consent of my own free will. Type your name as your digital signature  * required Your email address:  * required

This is a Disclosure Statement-req. by DORA DISCLOSURE STATEMENT 1. Name: Deborah M Lundquist Business address: 3560 Evergreen Parkway, #204 P. O. Box 775 Evergreen, CO 80437 Business telephone number: (303) 670-1726 2. My degrees are: Red Rocks Community College, 1984, Associate of Applied Science in Solar Energy Technology My credentials are: Diploma from Hypnotherapy Academy of America, certifying 250 hours of completed study and the title of Hypnotherapist. Member of the American Council of Hypnotist Examiners, No. CHT 405-187. 120 hours of additional training in Regression Therapy by Dr. Linda Backman, Ed. D., and 100 hours of Clinical Hypnotherapy training plus diploma from Hypnotherapy Academy of America. Completed training with Dolores Cannon for Level 1 (2012) and Level 2 (2015). 3. The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting, and unlicensed individuals who practice psychotherapy. The agency within the Department that has responsibility specifically for licensed and unlicensed psychotherapists is the Department of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7766. 4. Client Rights and Important Information:- a. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information. b. You can seek a second opinion from another therapist or terminate therapy at any time. c. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies, Mental Health Section. d. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a licensed marriage and family therapist, a licensed social worker, a licensed professional counselor, a licensed psychologist, or an unlicensed psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client's consent. Information disclosed to a licensed marriage and family therapist, a licensed social worker, a licensed professional counselor, a licensed psychologist, or an unlicensed psychotherapist is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates. There are exceptions to the general rule of legal confidentiality. These exceptions are listed in the Colorado statutes (C.R.S. 12-43-218). You should be aware that provisions concerning disclosure of confidential communications shall not apply to any delinquency or criminal proceedings, except as provided in section 13-90-107 C.R.S. There are exceptions that I will identify to you as the situations arise during therapy. 5. If you have any questions or would like additional information, please feel free to ask. I have read the preceding information and understand my rights as a client/ patient. NOTE: In RESIDENTIAL, INSTITUTIONAL, or other settings where psychotherapy may be provided by multiple providers, the primary therapist makes the above disclosure. The INSTITUTION must also provide a disclosure. (See C.R.S. 12-43-214(3)) Type your name as your Digital Signature  * required Valid email address  * required