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If you are interested in utilizing Earthways Healing's Therapeutic services please fill out the following form:


Earthways Healing Intake Form

Date of Birth
Month
Day
Year

Insurance Information

How did you hear about us?
Friend
Family member
Google search
Social Media
Other (please specify)

Mental Health History

Have you previously received any type of mental health services (psychotherapy, psychiatric services etc.)?
No
Yes
Mental Health symptoms currently experiencing (Please check all that apply):

Medical History

Social History

Legal History

Do you have any past, current and or pending legal issues?
No
Yes

Education

Education level
GED / HSED
High School
Associates
Bachelors
Masters
Doctorate

Thank you for taking the time to fill out the above information. This information is helpful for our practitioners / providers to assist you during your healing journey.


Please review the following:


Earthways Healing – Policies, Terms & Conditions & Consent to Services


Informed Consent:

Nature of Services

Earthways Healing provides a variety of holistic and educational services, including however not limited to:

  • IntuitiveCare (is similar to psychotherapy or counseling)

  • Coaching and personal development services

  • Energy work (e.g. Earth Spirit Medicine Reiki, spiritual consultation, sound healing, etc)

  • Group classes/trainings, workshops, and retreats

  • Brain spotting and other somatic-based healing practices that may be used

Disclaimer: Even though the practitioner is a Licensed Professional Counselor in WI and is legally capable of facilitating psychotherapy, these services are considered non-clinical and are intuitive, holistic and alternative in nature. Coaching, energy healing, and spiritual consultations are not a substitute for licensed mental health treatment. These services are considered complementary and should not replace medical or psychiatric care.

Terms & Conditions:

Pre-Purchased Services: Any and all pre-purchased services are non-refundable. Any unused services will be considered forfeited after six (6) months have passed from the last date service used.

Cancellation Policy: If any service is canceled by the client less than twenty-four (24) hours’ notice, the session will be considered forfeited and will count as if the service occurred. Cost is FULL price of session.

If service is canceled more than 24 hours, cancelation fee is ½ the cost of the service however, this does not include Package plans because Package plans are already set at a discounted rate.

Right to Modify: Earthways Healing (EWH) reserves the right to modify, update, or change their prices, policies, terms & conditions at any time without prior notice.

Scheduling

  • Scheduling: After purchasing any service (individual session or package plan), the sessions will be scheduled by client or the practitioner through Calendly, if there is a conflict you may be notified and a staff person will contact you using the information provided to reschedule your session(s).

  • Practitioner Availability: Availability varies. The online calendar may not reflect current openings due to software incompatibilities – calendars not communicating with each other.

Client Responsibilities

  • Ensure that your contact information is accurate at the time of booking.

  • Respond promptly to communication to secure your desired appointment times.

  • Stay informed of Earthways Healing’s policies, terms & conditions and any other updates.

Practitioner Cancellations

In rare cases, the practitioner may need to reschedule due to unforeseen circumstances. You will be notified as soon as possible, and a new session time will be arranged.


Confidentiality

At Earthways Healing, LLC, we are committed to protecting your privacy and ensuring the confidentiality of your personal health information provided upon intake.  We comply with the Health Insurance Portability and Accountability Act (HIPAA) to safeguard your personal and medical data.

Our practices adhere to strict standards for the collection, use, and disclosure of protected health information (PHI). Your information is used only to provide support for your wellness journey.

If you have questions about how your information is handled, please contact us for more details on our privacy practices. Your trust is our priority.

  • Information shared in coaching, classes, and group settings is kept confidential to the extent possible but cannot be guaranteed in group formats.

  • For all services, confidentiality may be broken if (practitioner is considered a mandated reporter):

    • There is suspicion of child, elder, or vulnerable adult abuse

    • There is a threat of harm to self or others

    • Records are subpoenaed by a court of law

Risks and Benefits

Possible Benefits:

  • Greater self-awareness and personal healing

  • Improved well-being, relationships, and emotional regulation

  • Spiritual insight and energetic alignment

Possible Risks:

  • Temporary emotional discomfort as deep work unfolds

  • Shifts in relationships or personal identity as you grow

  • Rare but possible physical discomfort during physical practices (e.g., breathwork)

**Please communicate openly during sessions if anything feels unsafe or uncomfortable.

Communication and Technology Use

  • Sessions may occur in person, by phone, or via HIPAA-compliant video platforms.

  • Email and text communication are used for scheduling only and are not secure for confidential content.

  • Practitioners will respond during business hours unless otherwise arranged.

Consent and Acknowledgment

By receiving services from Earthways Healing, LLC, you acknowledge and agree that:

  • You have read and understood this Policies, Terms & Conditions & Informed Consent document.

  • You agree to participate in services offered by Earthways Healing, LLC.

  • You understand the limitations, risks, and benefits of the services.

  • You consent to the policies and practices outlined herein.

 

Please indicate that you have read and understood Earthways Healing – Policies, Terms & Conditions and Consent to Services by checking the box below.
Yes, I understand the above Earthways Healing LLC – Policies, Terms & Conditions and Consent to Services.
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