Intake form

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.   PLEASE READ IT CAREFULLY. Your Personal Health Information We collect personal health information from you through treatment, payment and related healthcare operations, the application and enrollment process, and/or healthcare providers or health plans, or through other means, as applicable. Your personal health information that is protected by law broadly includes any information, oral, written or recorded, that is created or received by certain health care entities, including health care providers, such as physicians and hospitals, as well as, health insurance companies or plans. The law specifically protects health information that contains data, such as your name, address, social security number, and others, that could be used to identify you as the individual patient who is associated with that health information. Uses or Disclosures of Your Personal Health Information Generally, we may not use or disclose your personal health information without your permission. Further, once your permission has been obtained, we must use or disclose your personal health information in accordance with the specific terms that permission. The following are the circumstances under which we are permitted by law to use or disclose your personal health information. Without Your Consent Without your consent, we may use or disclose your personal health information in order to provide you with services and the treatment you require or request, or to collect payment for those services, and to conduct other related health care operations otherwise permitted or required by law. Also, we are permitted to disclose your personal health information within and among our workforce in order to accomplish these same purposes. However, even with your permission, we are still required to limit such uses or disclosures to the minimal amount of personal health information that is reasonably required to provide those services or complete those activities.  Examples of treatment activities include: (a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation between health care providers relating to a patient; or (c) the referral of a patient for health care from one health care provider to another. Examples of payment activities include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities; and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement. Examples of health care operations include: (a) development of clinical guidelines; (b) contacting patients with information about treatment alternatives or communications in connection with case management or care coordination; (c) reviewing the qualifications of and training health care professionals; (d) underwriting and premium rating; (e) medical review, legal services, and auditing functions; and (f) general administrative activities such as customer service and data analysis. As Required By Law We may use or disclose your personal health information to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law.  Examples of instances in which we are required to disclose your personal health information include: (a) public health activities including, preventing or controlling disease or other injury, public health surveillance or investigations, reporting adverse events with respect to food or dietary supplements or product defects or problems to the Food and Drug Administration, medical surveillance of the workplace or to evaluate whether the individual has a work-related illness or injury in order to comply with Federal or state law; (b) disclosures regarding victims of abuse, neglect, or domestic violence including, reporting to social service or protective services agencies; (c) health oversight activities including, audits, civil, administrative, or criminal investigations, inspections, licensure or disciplinary actions, or civil, administrative, or criminal proceedings or actions, or other activities necessary for appropriate oversight of government benefit programs; (d) judicial and administrative proceedings in response to an order of a court or administrative tribunal, a warrant, subpoena, discovery request, or other lawful process; (e) law enforcement purposes for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person, or reporting crimes in emergencies, or reporting a death; (f) disclosures about decedents for purposes of cadaveric donation of organs, eyes or tissue; (g) for research purposes under certain conditions; (h) to avert a serious threat to health or safety; (i) military and veterans activities; (j) national security and intelligence activities, protective services of the President and others; (k) medical suitability determinations by entities that are components of the Department of State; (l) correctional institutions and other law enforcement custodial situations; (m) covered entities that are government programs providing public benefits, and for workers’ compensation. All Other Situations, With Your Specific Authorization Except as otherwise permitted or required, as described above, we may not use or disclose your personal health information without your written authorization.  Further, we are required to use or disclose your personal health information consistent with the terms of your authorization.  You may revoke your authorization to use or disclose any personal health information at any time, except to the extent that we have taken action in reliance on such authorization, or, if you provided the authorization as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy. Miscellaneous Activities, Notice We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.  We may contact you to raise funds for Rocksteady Life.   Your Rights With Respect to Your Personal Health Information Under HIPAA, you have certain rights with respect to your personal health information. The following is a brief overview of your rights and our duties with respect to enforcing those rights. Right To Request Restrictions On Use Or Disclosure You have the right to request restrictions on certain uses and disclosures of your personal health information about yourself. You may request restrictions on the following uses or disclosures: to carry out treatment, payment, or healthcare operations; (b) disclosures to family members, relatives, or close personal friends of personal health information directly relevant to your care or payment related to your health care, or your location, general condition, or death; (c) instances in which you are not present or your permission cannot practicably be obtained due to your incapacity or an emergency circumstance; (d) permitting other persons to act on your behalf to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of personal health information; or (e) disclosure to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. While we are not required to agree to any requested restriction, if we agree to a restriction, we are bound not to use or disclose your personal healthcare information in violation of such restriction, except in certain emergency situations.   We will not accept a request to restrict uses or disclosures that are otherwise required by law. Right To Receive Confidential Communications You have the right to receive confidential communications of your personal health information.  We may require written requests.  We may condition the provision of confidential communications on you providing us with information as to how payment will be handled and specification of an alternative address or other method of contact.  We may require that a request contain a statement that disclosure of all or a part of the information to which the request pertains could endanger you.  We may not require you to provide an explanation of the basis for your request as a condition of providing communications to you on a confidential basis. We must permit you to request and must accommodate reasonable requests by you to receive communications of personal health information from us by alternative means or at alternative locations.   Right To Inspect And Copy Your Personal Health Information  Your designated record set is a group of records we maintain that includes Medical records and billing records about you, or enrollment, payment, claims adjudication, and case or medical management records systems, as applicable.  You have the right of access in order to inspect and obtain a copy your personal health information contained in your designated record set, except for (a) psychotherapy notes, (b) information complied in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding, and (c) health information maintained by us to the extent to which the provision of access to you would be prohibited by law.  We may require written requests.  We must provide you with access to your personal health information in the form or format requested by you, if it is readily producible in such form or format, or, if not, in a readable hard copy form or such other form or format.  We may provide you with a summary of the personal health information requested, in lieu of providing access to the personal health information or may provide an explanation of the personal health information to which access has been provided, if you agree in advance to such a summary or explanation and agree to the fees imposed for such summary or explanation. We will provide you with access as requested in a timely manner, including arranging with you a convenient time and place to inspect or obtain copies of your personal health information or mailing a copy to you at your request.  We will discuss the scope, format, and other aspects of your request for access as necessary to facilitate timely access.  If you request a copy of your personal health information or agree to a summary or explanation of such information, we may charge a reasonable cost-based fee for copying, postage, if you request a mailing, and the costs of preparing an explanation or summary as agreed upon in advance. We reserve the right to deny you access to and copies of certain personal health information as permitted or required by law.  We will reasonably attempt to accommodate any request for personal health information by, to the extent possible, giving you access to other personal health information after excluding the information as to which we have a ground to deny access.  Upon denial of a request for access or request for information, we will provide you with a written denial specifying the legal basis for denial, a statement of your rights, and a description of how you may file a complaint with us.  If we do not maintain the information that is the subject of your request for access but we know where the requested information is maintained, we will inform you of where to direct your request for access.

1) Rocksteady Life-Client Relationship A. The Client is solely responsible for creating and implementing their own physical, mental and emotional well-being, decisions, choices, actions and results arising out of or resulting from our relationship and their calls and interactions with Rocksteady Life. As such, the Client agrees that Rocksteady Life is not and will not be liable or responsible for any actions or inaction, or for any direct or indirect result of any services provided by Rocksteady Life. The Client understands that a session with Rocksteady Life is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease. B. The Client further acknowledges that they may terminate or discontinue the relationship at any time. C. The Client acknowledges that coaching is a comprehensive process that may involve different areas of their life, including work, finances, health, relationships, education and recreation. The Client agrees that deciding how to handle these issues, incorporate coaching principles into those areas and implementing choices is exclusively the Client’s responsibility. D. The Client acknowledges that sessions do not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and that coaching is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals and that it is the Client’s exclusive responsibility to seek such independent professional guidance as needed. If the Client is currently under the care of a mental health professional, it is recommended that the Client promptly inform the mental health care provider of the nature and extent of the relationship agreed upon by the Client and Rocksteady Life. E. The Client understands that in order to enhance the relationship, the Client agrees to communicate honestly, be open to feedback and assistance and to create the time and energy to participate fully in their sessions. 2) Services Sally Palmer Rocksteady Life 275 East 4th Street, Suite 812 St. Paul, MN 55101 The parties agree to engage in a relationship that can be ended at any time. Rocksteady Life will be available to the Client by text, e-mail and voicemail in between scheduled meetings as defined by Rocksteady Life. All phone calls, video calls and in-person sessions will be charged on a sliding scale fee structure as agreed upon by the two parties. Sally Palmer is a certified Craniosacral Therapist through the Heartwood Institute, a certified Somatic Experiencing Practitioner, Karuna Reiki Master, Animal Reiki Master, INELDA-trained End of Life Doula, certified Biofield Tuning Practitioner and Sonic Anatomy Guide with a Master’s Degree in Publishing and Print Culture. Services may include, but are not limited to diet and nutrition evaluation and guidance, hands-on therapies, lifestyle suggestions, Somatic Experiencing, Biofield Tuning, Craniosacral Therapy, Reiki, Crystal Singing bowls, Singing/Toning, sessions outside at Lake Como and in-home appointments. The Client understands that Rocksteady Life neither claims nor implies that any instruction, advice, recommendations, services, or herbal/nutritional products the practitioner provides or recommends will cure, treat, prevent or mitigate any disease condition, but are provided solely for the purpose of nourishing and strengthening the natural function of the various body organs and systems so that they may have a greater capacity to heal themselves. The Client understands that Rocksteady Life believes many diseases are related to unresolved emotional conflicts. The Client understands that counseling or assistance offered in this area is done on a spiritual basis and does not replace licensed psychiatric care or professional counseling. The Client requests the advice and assistance of Rocksteady Life in helping them to learn what they can do to improve their health and fitness. The Client requests this information and any products or services that may attend it as their right to Freedom of Choice in Medicine and Health care retained by them under the Ninth Amendment to the U.S. Constitution, of certain rights, that shall not be construed to deny or disparage others retained by this person. 3) Procedure The time of the sessions and/or location will be determined by Rocksteady Life and Client based on a mutually agreed upon time. The Client will initiate all scheduled calls and will call Rocksteady Life at the following number for all scheduled meetings (651) 560-0878. If Rocksteady Life will be at any other number for a scheduled call, the Client will be notified prior to the scheduled appointment time. 4) Confidentiality This relationship, as well as all information (documented or verbal) that the Client shares with Rocksteady Life as part of this relationship, is bound by the principles of confidentiality set forth in the ICF Code of Ethics. However, please be aware that the Rocksteady Life-Client relationship is not considered a legally confidential relationship (like the medical and legal professions) and thus communications are not subject to the protection of any legally recognized privilege. Rocksteady Life agrees not to disclose any information pertaining to the Client without the Client’s written consent. Rocksteady Life will not disclose the Client’s name as a reference without the Client’s consent. Confidential Information does not include information that: (a) was in Rocksteady Life’s possession prior to its being furnished by the Client; (b) is generally known to the public or in the Client’s industry; (c) is obtained by Rocksteady Life from a third party, without breach of any obligation to the Client; (d) is independently developed by Rocksteady Life without use of or reference to the Client’s confidential information; or (e) Rocksteady Life is required by statute, lawfully issued subpoena, or by court order to disclose; (f) is disclosed to Rocksteady Life and as a result of such disclosure Rocksteady Life reasonably believes there to be an imminent or likely risk of danger or harm to the Client or others; and (g) involves illegal activity. The Client also acknowledges their continuing obligation to raise any confidentiality questions or concerns with Rocksteady Life in a timely manner. According to the ethics of our profession, topics may be anonymously and hypothetically shared with other coaching professionals for training, supervision, mentoring, evaluation, and for coach professional development and/or consultation purposes. 5) Cancellation Policy Client agrees that it is the Client’s responsibility to notify Rocksteady Life 2 hours in advance of the scheduled calls/meetings. Rocksteady Life reserves the right to bill the Client for a missed meeting. Rocksteady Life will attempt in good faith to reschedule the missed meeting. 6) Record Retention Policy The Client acknowledges that Rocksteady Life has disclosed their record retention policy with respect to documents, information and data acquired or shared during the term of the Rocksteady Life-Client relationship. Such records will be maintained by Rocksteady Life in a format of the Coach’s choice (print or digital/electronic) for a period of not less than 2 years. 7) Termination Either the Client or Rocksteady Life may terminate this Agreement at any time. The client agrees to compensate Rocksteady Life for all services rendered through and including the effective date of termination of the relationship. 8) Limited Liability Except as expressly provided in this Agreement, Rocksteady Life makes no guarantees, representations or warranties of any kind or nature, express or implied with respect to the coaching services negotiated, agreed upon and rendered. In no event shall Rocksteady Life be liable to the Client for any indirect, consequential or special damages. Notwithstanding any damages that the Client may incur, Rocksteady Life’s entire liability under this Agreement, and the Client’s exclusive remedy, shall be limited to the amount actually paid by the Client to Rocksteady Life under this Agreement for all coaching services rendered through and including the termination date. 9) Entire Agreement This document reflects the entire agreement between Rocksteady Life and the Client, and reflects a complete understanding of the parties with respect to the subject matter. This Agreement supersedes all prior written and oral representations. The Agreement may not be amended, altered or supplemented except in writing signed by both Rocksteady Life and the Client. 10) Dispute Resolution If a dispute arises out of this Agreement that cannot be resolved by mutual consent, the Client and Rocksteady Life agree to attempt to mediate in good faith for up to 30 days after notice given. If the dispute is not so resolved, and in the event of legal action, the prevailing party shall be entitled to recover attorney’s fees and court costs from the other party. 11) Severability If any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If the Court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited. 12) Waiver The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party’s right to subsequently enforce and compel strict compliance with every provision of this Agreement. 13) Applicable Law This Agreement shall be governed and construed in accordance with the laws of the State of Minnesota , without giving effect to any conflicts of laws provisions. 14) Binding Effect This Agreement shall be binding upon the parties hereto and their respective successors and permissible assigns.

To proceed with receiving care, I confirm and understand the following I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources.I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult. I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care. I can access a copy of this consent form. I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM ROCKSTEADY LIFE.

PRIVACY NOTICE: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

PRIVACY NOTICE: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

*Energy medicine is a collective term used that refers to a variety of energy techniques, processes, and methods based on the use, modification, and manipulation of energy fields that look at imbalances within an individual’s energy system as well as the energetic influence of thoughts, beliefs, and emotions on the body.

All clients are given one “hall pass” to use for a free cancellation, whether it’s 24-hour notice or same-day. The client can make that choice. Any cancellation fee will be billed via Venmo, if that is the preferred method of payment for the client.