For legal and ethical purposes, the client must read and agree to the outline of how I conduct my practice and what I expect from them. This is a combined client bill of rights and disclosure statement. There is also an intake form for new clients.
What you will see on my forms:
Andréa Kremposky- Drémari Holistic Wellness
Informed Consent for
Wellness & Nutrition –Holistic Health
Welcome to my practice! I look forward to helping you achieve sustainable health and vitality based on your individuality. The following information describes the philosophical and legal bases for my services, and provides several considerations for us to ensure we agree upon as we begin working together. Please review, sign and return (or state your agreement with name and date for distance work) the intent/consent form before our session.
What I provide and what I expect from you:
As a nutritional consultant and wellness coach I do not diagnose or treat disease. The intent of my nutritional and lifestyle guidance is to support optimal function of the physiological and biological processes of your body. The consultation I provide will include individualized dietary recommendations appropriate to your health goals. In addition, since lifestyle habits such as exercise, stress and connection with others are essential to health, these may also be focal points of our work together. Improvement in your health will primarily rest upon YOU! I will provide you with information and practical suggestions for implementing recommended changes, but you are the person who ultimately makes it happen.
*All conditions, medicines, botanicals, and nutritional supplements are disclosed in the evaluation, as interactions and contraindications are a concern. Your safety is of the utmost importance.
*By choosing complementary methods and supplements, it is your responsibility to inform your healthcare providers (primary care provider, specialist, etc.) that you are taking herbs and supplements. Some may interfere with the healthcare provider’s treatments and prescriptions.
Experience- my story: I have life-long experience with the holistic health world. My mother was a registered nurse. She began the business long before I was involved. Holistic healing along with her own efforts allowed her to make a recovery from environmental illness/ chemical sensitivity causing her to only be able to eat a few vegetables, rice cakes and wild game meat, not being able to go into stores to eating pretty much anything and gaining vitality. I was taught about herbs and muscle response testing by “the herb lady” when I was 8 years old. A chiropractor/ nutritionist/ acupuncturist/ applied kinesiologist is the one who helped my mom get to her recovery. He taught me the basics of applied kinesiology and how the meridian system, energy and emotions influence health. I put health skills into practice caring for my grandmother after her stroke. She was only supposed to have 6-8 months of life left due to the debilities the stroke caused. She lived and thrived for 9 years in fair condition while being bed-fast. Her doctor and the nurses were amazed. I studied the body system balance, herbs and nutrition before moving on to an accredited college to work on an official degree in Complementary and Alternative Medicine. I wanted to put all I have learned into practice to benefit others.
Licensure. I am not licensed by the State of Pennsylvania as a holistic health practitioner. Services I provide to you should be considered as complementary to medical treatment you are receiving from a licensed healthcare professional. Please inform your primary care provider that you are working with a holistic health practitioner. I am happy to collaborate with your other providers with your permission.
I do not have the authority to practice medicine or undertake the diagnosis, treatment or cure of any disease, pain, deformity, injury, or mental or physical condition. Only a licensed medical professional may state that any product or method might cure any disease, disorder or condition. I may recommend that a licensed medical/ healthcare professional evaluate a condition I feel is beyond the scope of nutritional/ holistic work.
A client that is referred to me will be referred back to the original practitioner once the presenting issue is complete. I will work WITH the original practitioner for the good of the client, as the client sees fit.
What I do NOT do:
- Surgery or any other procedure on another person that punctures the skin or harmfully invades the body.
- Administer or prescribe X-ray radiation.
- Prescribe or administer legal drugs or controlled substances to another person.
- Recommend the discontinuance of legal drugs or controlled substances prescribed by an appropriately licensed practitioner.
- Willfully diagnosing and treating a physical or mental condition of any person under any circumstances or conditions that cause or create a risk of great bodily harm, serious physical illness, or death.
- Setting fractures.
- Treating lacerations or abrasions through electrotherapy.
- Holding out, stating, indicating, advertising or implying to a prospective client that he or she is a physician and/or a surgeon.
Investment: We will discuss and finalize by the end of our first meeting the initial investment to support you in healing. I will send you a receipt for purchased services after our first session. My hourly fee (average cost $60/hour) covers the time we are actively in session together, as well as the time I spend preparing for our session, and the time I spend following our session to write up my recommendations. I spend extensive research time to ensure the recommendations are not contraindicated. Know that I do a lot of research work for your benefit and it is my honor to provide this service for you.
Fees, Payment Schedule, and Services: Sessions price is agreed upon based on what you select and may last for one hour. Overage is $1 per minute beyond appointment time. The payment is due before the start of each session. Payment through PayPal is accepted. Note that there is no insurance coverage for these sessions.
I request that you provide at least a 24 hour notice if you need to cancel or reschedule your appointment, otherwise you will be charged for the session in full.
Confidentiality. Confidentiality is an important element of the client-practitioner consultation process. Your identity and ongoing work will be kept strictly confidential. I will only release information about our work with your written permission, or if I am required by court order.
The following exceptions will apply:
- There are a broad range of events that are reportable under child protection statutes. Physical or sexual abuse of a child will be reported to Child Protective Services. When the victim of child abuse is over age 18, I am not legally mandated to report it unless I believe that there are minors still living with the abuser who may be in danger of being abused. Elder abuse is also required to be reported to the appropriate authorities.
- If you are at imminent risk to yourself or someone else or make threats of imminent violence against another person, I will take appropriate action.
Anyone under age 18 must be accompanied by a parent or legal guardian.
By working with me, you agree any product supplied or recommended by me is only for the client named. I am not responsible for products purchased and given to someone I have not had contact with or evaluated. The following must be addressed:
- other medications or products being used 2. pregnancy, breastfeeding, or might become pregnant 3. contraindications or pre-existing medical condition 4. make sure each product is appropriate for the situation. You will not resale products I provide to individuals or online.
You have a right to refuse any recommendation.
Ultimately, deciding what is best for your health is solely in your discretion. You are welcome to do further research on my recommendations. I also encourage you to discuss the recommendations with your healthcare provider.
Acknowledgment and Release of Liability
By signing this disclosure and consent statement, I acknowledge that I understand the above information. I agree to hold harmless Andréa Kremposky from all liabilities and claims which may arise as a result of my participation in health, wellness, and nutrition consulting and/or consuming nutritional supplements. Client assumes sole responsibility and freely chooses to follow recommendations.
_____________________________________ ________________
Signature of client Date
_____________________________________ _________________
Signature of legal guardian Date
___________________________________________
For the Energy Work (it is nearly identical):
Andréa Kremposky- Drémari Holistic Wellness
Informed Consent for Energy Healing
Welcome to my practice! I look forward to helping you achieve sustainable health and vitality based on your individuality. The following information describes the philosophical and legal bases for my services, and provides several considerations for us to ensure we agree upon as we begin working together. Please review, sign and return (or state your agreement with name and date for distance work) the intent/consent form before our session.
Improvement in your health will primarily rest upon YOU! I will provide you with information and practical suggestions for implementing recommended changes, but you are the person who ultimately makes it happen.
***In energy work, “medicine” and “healing” are general, interchangeable terms associated with age-old practices and are not intended to promote or suggest the practice of medicine such as diagnoses, treatment, and cures.
“I understand that energy medicine is a simple and gentle energy technique that is used for stress reduction and relaxation. I understand that energy medicine practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that energy healing does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that energy work can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.” Your initials: __________
Licensure. I am not licensed by the State of Pennsylvania as a healing arts practitioner. Services I provide to you should be considered as complementary to medical treatment you are receiving from a licensed healthcare professional I am happy to collaborate with your other providers with your permission.
Due to Pennsylvania laws, I cannot use hands-on techniques. Hands-off methods and distance work is equally effective, as energy has no time or space.
I do not have the authority to practice medicine or undertake the diagnosis, prevention, treatment or cure of any disease, pain, deformity, injury, or mental or physical condition. Only a licensed medical professional may state that any product might cure any disease, disorder or condition. I may recommend that a licensed medical/ healthcare professional evaluate a condition I feel is beyond the scope of nutritional/ holistic work.
A client that is referred to me will be referred back to the original practitioner once the presenting issue is complete. I will work WITH the original practitioner for the good of the client, as the client sees fit.
What I do NOT do:
- Surgery or any other procedure on another person that punctures the skin or harmfully invades the body.
- Administer or prescribe X-ray radiation.
- Prescribe or administer legal drugs or controlled substances to another person.
- Recommend the discontinuance of legal drugs or controlled substances prescribed by an appropriately licensed practitioner.
- Willfully diagnosing and treating a physical or mental condition of any person under any circumstances or conditions that cause or create a risk of great bodily harm, serious physical illness, or death.
- Setting fractures.
- Treating lacerations or abrasions through electrotherapy.
- Holding out, stating, indicating, advertising or implying to a prospective client that he or she is a physician and/or a surgeon.
Investment: We will discuss and finalize by the end of our first meeting the initial investment to support you in healing. I will send you a receipt for purchased services after our first session. My hourly fee covers the time we are actively in session together, as well as the time I spend preparing for our session, and the time I spend following our session to write up my recommendations.
Fees, Payment Schedule, and Services: Sessions are priced per session. Please allow for one hour at minimum. The payment is due before the start of each session. Payment through PayPal is accepted. Note that there is no insurance coverage for these sessions.
I request that you provide at least a 24 hour notice if you need to cancel or reschedule your appointment, otherwise you will be charged for the session in full.
Confidentiality. Confidentiality is an important element of the client-practitioner consultation process. Your identity and ongoing work will be kept strictly confidential. I will only release information about our work with your written permission, or if I am required by court order.
The following exceptions will apply:
- There are a broad range of events that are reportable under child protection statutes. Physical or sexual abuse of a child will be reported to Child Protective Services. When the victim of child abuse is over age 18, I am not legally mandated to report it unless I believe that there are minors still living with the abuser who may be in danger of being abused. Elder abuse is also required to be reported to the appropriate authorities.
- If you are at imminent risk to yourself or someone else or make threats of imminent violence against another person, I will take appropriate action.
Anyone under age 18 must be accompanied by a parent or legal guardian.
By working with me, you agree any product supplied or recommended by me is only for the client named. I am not responsible for products purchased and given to someone I have not had contact with or evaluated. The following must be addressed:
- other medications or products being used B. pregnancy or breastfeeding or might become pregnant C. contraindications or pre-existing medical condition D. make sure each product is appropriate for the situation. You will not resale products I provide to individuals or online.
You have a right to refuse any recommendation.
Ultimately, deciding what is best for your health is solely in your discretion. You are welcome to do further research on my recommendations. I also encourage you to discuss the recommendations with your healthcare provider.
Acknowledgment and Release of Liability
By signing this disclosure and consent statement, I acknowledge that I understand the above information. I agree to hold harmless Andréa Kremposky from all liabilities and claims which may arise as a result of my participation in health, wellness and nutrition consulting, and/or energy work. Client assumes sole responsibility and freely chooses to follow recommendations.
_____________________________________ ________________
Signature of client Date
_____________________________________ _________________
Signature of legal guardian Date
Drémari Holistic Wellness 