Please fill out this basic Client Intake Form and send it back to me.
Please sign and send back this form. There is a feature in Microsoft Word that allows you to "draw" your signature on the file. Then save and send back. Or you can print it out and send me a picture of it.
Personal History Form
Please fill out the Personal History Form and send back to me at least the day before your first appointment. Just save your answers in the Word document and send it back to me.
Emily Eby, Healing Services
California Client Information Form, Acknowledgement, & Consent to Receive Treatment (In accordance with California Senate Bill SB-577 and Colorado Senate Bill SB-215)
What are Healing Services?
Healing services as listed by Emily Eby are intuitive coaching, emotional and spiritual healing, and inner child healing. Intuitive coaching helps you change your life by accessing your intuition and fulfilling your goals. Emotional and spiritual healing identifies wounds from the past that keep you from functioning in the present, then helps heal those wounds. Inner child healing is a tool that assists in healing past wounds, especially those from childhood, by way of reparenting.
What Healing Services is not
Your practitioner is not a licensed physician, and Healing Services does not require licensing by the state. They are meant to be a complement to “healing arts services licensed by the state”; i.e., they are a complement to traditional Western medicine provided by doctors, nurses, and other licensed medical professionals. These services are not intended to diagnose or treat psychiatric disorders.
Theory of Treatment
Emotional, mental, and spiritual healing is widely accepted as effective in society, and across many different professional fields. Disruptions to our development and unresolved wounds lead to a myriad of problems be it mental, physical, or emotional. The Healing Services offered aim to understand and resolve patterns, belief systems and behaviors that no longer serve you and may be the direct cause of suffering now.
It is the goal of this practitioner to help resolve the presenting problems as quickly as possible. This could be anywhere from 3 sessions to 6 months. It is very difficult to predict how many sessions or how long a healing process will take because it is a process. Vital to progress is the client’s full commitment to the healing process (i.e. willingness to take the steps for change). You and Emily will discuss your particular needs and come up with a plan and time frame that fits for you.
Nature of the Services Provided
Before the first session the client will be required to fill out a questionnaire addressing family of origin and other pertinent historical information. This will allow Emily to gather huge amounts of information in a short period of time and accelerate the process. The first one to three sessions are about getting to know each other and building trust. By way of your questionnaire we will be exploring your presenting or primary problems and looking for the root cause. That is a major focus of the Healing Services; finding the root cause of the problem. Once the cause is established, we start to move forward from there. Reworking all the belief systems that have been affected by the initial disruption.
This reworking is done through many different tools: restoring intuition, inner child work, and education and discussion. Emily uses her training and experience to determine which is right for the person and for the moment. Eventually, the client takes on the expert role for themselves, deciding which tool is needed for each challenge. It could be said that Emily first functions in a reparenting role, providing the client and their inner child with all the things they need but never got. This teaches the client to listen to their own intuition. As the client heals they then take over and begin to reparent themselves.
The client and the practitioner can meet in a variety of ways. In-person, phone and video sessions are available.
Fee Exchange for Service
$150 per hour
The full price of the session will be charged if the client does not give at least 24 hour’s notice.
Currently, Emily works Monday, Tuesday, Wednesday, and Friday. Which means Emily is not available to respond to emails or phone calls on Thursday, Saturday, or Sunday. Emily is not available for emergency services; she is only working and available during business hours.
Emily books all her sessions through an online scheduling system. It is through this scheduling system that you will also pay for your session. Payment is required at time of scheduling. It is through this system you can also reschedule your own session, before the 24 hour limit mentioned above. It is essentially a first come, first served situation.
Pausing and Ending Sessions
If you don’t schedule a session for a longer period of time (2-3 months) Emily will assume that you have paused your sessions; perhaps ended and no longer needing sessions. After this period of time, Emily will allow for new clients to enter the flow. Filling in the now open space. If you have a gap in scheduling and know that you want to return please let Emily know. And arrangements could be made.
Emily believes that everyone has a rhythm with their healing work and she trusts that you will schedule when its right for you.
Emily Eby’s Qualifications
Emily Eby, MA earned her master’s degree in Counseling Psychology from the University of Colorado Denver in 2008. She obtained her license in professional counseling in Colorado, although she does not have an active license now. She’s had nearly 100 hours of post-graduate training in trauma resolution therapy: psychodrama, relational trauma repair with Tian Dayton, trauma therapy training with Judy Crane of The Refuge, Somatic Experiencing training, and trauma therapy training with Pia Mellody (a pioneer in the field of codependency).
Emily has also created and presented professional workshops and presentations to train other therapists and healers how to heal trauma and codependency. For example: Colorado Counseling Associations Annual Conference, continuing education for PEER assistance in Colorado, People House Continuing Education series and three other professional training workshops in Colorado.
Acknowledge & Consent to Receive
In order to use Emily Eby’s services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will be provided with a copy for signature at your first visit. Emily will keep the original in her records for three (3) years.
I have read and understand the above guidelines and disclosure about the treatments and techniques offered by Emily Eby, MA, as well as her training and education.
I have discussed with Emily any concerns I have about the nature of the treatment that she will be providing.
If I experience any discomfort during the session(s), I agree to immediately inform Emily.
I understand that Emily is not a licensed physician and that the alternative services that she will be providing to me are not licensed by the State of California.
I understand that it is my responsibility to maintain a relationship for myself and/or my child with a medical doctor.
I understand that Healing Services are not a substitute for medical treatment or medications. I am aware that Emily Eby does not diagnose illness or disease nor does she prescribe medications or recommend supplements. I understand that any suggestions that are provided to me should not be taken as a diagnosis or recommendation against the advice of a licensed physician or mental health professional.
I have consented to use the services offered by Emily Eby, and I agree to be personally responsible for her fees in connection with the services provided.
If requested, I have been provided with a copy of California Senate Bill SB-577.
I understand that Emily Eby does not carry malpractice insurance.