Fees

fees & forms

Fees & Forms

To allow more time for interactive work in your first private session, you can copy and paste the Integrative Mindworks Registration Form (below the Disclosure Form) into your word processing program, fill it out and return it electronically, or print it out to bring with you.

Private Session Fees are listed within the disclosure statement, below.

To register for a workshop or group class, please copy and complete the appropriate registration form and mail it with payment so it arrives before the registration deadline.

DISCLOSURE FORM

(please read before registering)

The Process of Mindworks

Mindworks is designed to open doors to self-knowledge, interrupt self-sabotaging patterns of thought and behavior, and reinforce self-supporting core beliefs and habits. Our work together is a partnership forged with the common intention of bringing you to a higher state of health and well-being. Your role is to let yourself receive assistance and allow those parts of you that have been part of the problem to become part of the solution. My role is to guide and facilitate this process. Working together, we can create lasting changes that will transform your life.

Scope of Practice

I provide holistic counseling, mind/body education, stress management and energy therapies to enhance wellness, increase ease, raise proficiency, and facilitate healing. I am not a licensed health care provider and am therefore not qualified to diagnose or prescribe treatment to cure any specific physical, mental or emotional disorder. As a hypnotherapist certified through the American Council of Hypnotist Examiners, I may use hypnosis within the legal limits of my training, competence and education, and in conformance with Federal, State and Local laws.

If you have any physical, mental or emotional disorder and have not yet sought the advice of a qualified health professional about your condition, please do so before scheduling an Integrative Mindworks session. I am happy to work with you in conjunction with your traditional healthcare providers. If you have already consulted a medical or psychological professional and have not gotten the results you seek, I will provide you with a gentle, holistic process that may or may not resolve your issue. I ask only that you come with a sincere desire and intention to release what troubles you and a willingness to change for the better, whatever that may entail. The number of appointments and types of processes employed vary according to the individual needs and goals of each client.

Qualifications

I am a Certified Clinical Hypnotherapist (trained in the 200-hour program at the Hypnotherapy Institute of Spokane and tested and certified by the American Council of Hypnotist Examiners), with over 100 hours to date of additional advanced courses in Medical and Dental Hypnosis, Hypnotherapy for Children, Solution-Focused Counseling, Dissolving Depression, Clarity Process, Dream and Symbol Analysis, Art Therapy, and Teaching Self-Hypnosis. I received Registered Yoga Teacher (RYT) status with the Yoga Alliance after earning a 200-hour certification through Integrative Yoga Therapy. Other certifications include Emotional Freedom Techniques—Advanced Studies (EFT-ADV, 125 hours), BioSomatic Movement Education (102 hours), Stott Pilates Advanced Matwork (75 hours), and Usui Reiki Master Teacher (42 hours). Additional trainings include Biovalent manual therapy (82 hours), Light Body (100 hours), and Quantum Touch (30 hours) . I am currently pursuing a graduate degree in Counseling and maintain ongoing studies in advanced hypnotherapeutic processes, yoga therapy, mind/body wellness and energy therapies.

Confidentiality

All information provided by clients remains completely confidential and will only be shared with someone else at the client’s written request. Exceptions, by law, are situations where information is given about the current and ongoing abuse of a child or senior. This must be reported to the proper authorities.

Private Session Fees:

15 minute session: $20 30 minutes: $40 40-60 minutes: $75 60-90 minutes: $100

Payment is expected at time of service. Your insurance company may or may not offer reimbursement. Consult them prior to our appointment if this is a concern or prerequisite for your visit. Please inquire about discount or pro bono services if appropriate for your need.

Cancellations/Missed or Late Appointments

If you need to cancel your appointment, please do so by phone (leaving a voice-mail message) at least 24 hours in advance. You will be billed for any missed appointments at the appropriate rate for the session time you booked. Emergency cancellations (less than 24 hours in advance) are handled on an individual basis. If you are late to your appointment, it will still end at the appointed time; you forfeit the time you miss, so please be prompt.

This information sheet is yours to keep. Refer to it for policies and fees. It also provides the information your insurance company may ask for to see if they will reimburse you for your visits.

Please copy and paste the appropriate registration form below into your word processing program.

The Integrative Mindworks Client Form below is for Private Clients and for group classes and workshops including Birthing Prep, EFT, and Stress Management registration.

All new yoga students should use the Yoga Class Registration Form (scroll down to find).

INTEGRATIVE MINDWORKS CLIENT REGISTRATION FORM

Name:________________________________________________ Date:__________________

Phone(s):_________________________Address:____________________________________

E-mail: ______________________________________ Date of Birth:_____________________

How did you hear of my work?_____________________________________________________

Are you registering for a class, workshop or private session?______________________________

What is the chief concern that brought you here?_______________________________________

____________________________________________________________________________

Have you seen a health professional about this? Who?__________________________________

Are you currently under a doctor or therapist’s care for anything else? (describe) ______________

____________________________________________________________________________

Please describe any prescription medication you are currently taking.________________________

____________________________________________________________________________

What are the greatest stressors in your life, and how do you manage them?___________________

____________________________________________________________________________

What do you do for fun, pleasure or self-nurturing?_______________________________________

____________________________________________________________________________

Are you or have you been physically active? (describe)__________________________________

____________________________________________________________________________

How would you describe your diet/eating habits?______________________________________

____________________________________________________________________________

What (if any) nutritional supplements are you taking?____________________________________

____________________________________________________________________________

Have you ever received counseling services before? Briefly describe (when, for what, result, etc.)

_____________________________________________________________________________

Have you had any previous experience with hypnosis, energy therapies or yoga? If so, please elaborate.

_____________________________________________________________________________

Do you have any particular spiritual or religious orientation? If so, please describe.______________

_____________________________________________________________________________

What would you most like to accomplish in our work together?_____________________________

_____________________________________________________________________________

Are you comfortable receiving respectful, hands-on assistance? _______________

LIABILITY WAIVER and TREATMENT PERMISSION:

April Rubino strives to assist in your healing and create and maintain a safe and healthy physical, mental and emotional environment. However, since every therapeutic and educational activity, process or practice carries some risk of perceived or real harm, I agree to the following:

I understand that I am responsible for exercising care for my own safety and well-being. I will not engage in any activity that causes me physical discomfort or undue emotional distress. I will inform April Rubino of any concerns or questions I have concerning my ability to engage in the activity, process or practice I have chosen to participate in.

I hereby release and discharge April Rubino from any and all liability, claims or demands arising out of my participation in activities, processes or practices with April Rubino, including, but not limited to, losses caused by the negligence of the Released Party.

I further agree that I will not sue or make a claim against the Released Party for damages or other losses sustained as a result of my participation in activities, processes or practices with April Rubino. I also agree to indemnify and hold harmless the Released Party from all claims, judgments and costs, including attorneys fees, incurred in connection with any action brought as a result of my participation in activities, processes or practices with April Rubino.

I understand and acknowledge that no amount of care, caution, instruction or expertise can entirely eliminate all potential for a negative outcome, and I expressly and voluntarily assume all risk of personal discomfort or injury sustained while participating in activities, processes or practices with April Rubino whether or not caused by the negligence of the Released Party.

I have also read the Disclosure Statement materials and agree to abide by the policies and fees detailed therein.

Signed:________________________________________ Date:_______________

Name (Printed)______________________________________________________

If client is a minor, permission for treatment is granted by the undersigned Parent or Guardian:

Signed:_________________________________ Relationship:_______________

Name (Printed)_____________________________________________________

YOGA CLASS REGISTRATION FORM

Name:_______________________________________________ Date:___________________

Phone(s):________________________Address:______________________________________

E-mail: __________________________________________ Date of Birth:__________________

What class are you registering for?__________________________________________________

Please list any old or current injuries, medical conditions, aches or pains that are troubling you or might affect your ability to participate in this class comfortably.

_____________________________________________________________________________

Are you currently under a doctor’s or therapist’s care or on medication? If so, please describe.

_____________________________________________________________________________

What physical pursuits (sports, dance, exercise, etc) have you been or are you now active in?

_____________________________________________________________________________

What previous training have you had in yoga, pilates, tai chi/qi gong or mindfulness?

_____________________________________________________________________________

What sorts of physical activities are you involved in day to day (sitting for long stretches,

computer work, heavy lifting, repetitive motion, etc.)?___________________________________

_____________________________________________________________________________

What are your goals in attending this class? What would you most like to accomplish?

_____________________________________________________________________________

Are you comfortable receiving respectful hands-on assistance?___________________________

LIABILITY WAIVER

April Rubino strives to assist in your healing and create and maintain a safe and healthy environment. However, since every physical, social, therapeutic and educational activity or practice carries some risk of harm, I agree to the following:

I understand that I am responsible for exercising care for my own safety and well-being. I will not engage in any activity that causes me physical pain or discomfort or undue emotional distress. I will inform April Rubino of any concerns or questions I have concerning my ability to engage in the activity I have come to participate in or observe. If I know or suspect that I have any medical problem or if I am under a doctor’s care, I will obtain my physician’s permission before participating in any activity or practice with April Rubino.

I hereby release and discharge April Rubino, as well as the facility owners and operators where she teaches or practices, from any and all liability, claims or demands arising out of my participation in activities or practices with April Rubino, including, but not limited to, losses caused by the negligence of the Released Parties.

I further agree that I will not sue or make a claim against the Released Parties for damages or other losses sustained as a result of my attendance of or participation in activities or practices with April Rubino. I also agree to indemnify and hold harmless the Released Parties from all claims, judgments and costs, including attorneys fees, incurred in connection with any action brought as a result of my participation in activities or practices with April Rubino.

I understand and acknowledge that these activities, gentle though they are, have potential dangers that no amount of care, caution, instruction or expertise can eliminate, and I expressly and voluntarily assume all risk of personal injury sustained while participating in activities or practices with April Rubino whether or not caused by the negligence of the Released Parties.

Signed:__________________________________________ Date:_______________

Name (Printed)_________________________________________________________