Disclosure and Informed Consent Form

(Required under California Senate Bill 577 - SB-577)

This document serves as a legally required disclosure and informed consent agreement between the practitioner and the client, as mandated by California Business and Professions Code Sections 2053.5 and 2053.6 (SB-577).

By signing this document, you acknowledge that you have been fully informed of the practitioner’s training, the nature of the services provided, and your right to refuse or terminate treatment at any time.

SECTION 1: PRACTITIONER INFORMATION AND DISCLOSURE

A. Practitioner Identity

  • Practitioner Name: [Your Full Name]

  • Business Name: [Your Business Name (if applicable)]

  • Primary Modality: CranioSacral Therapy (CST) and [List other modalities, e.g., Reiki, wellness coaching]

  • Contact Phone: [Your Phone Number]

  • Contact Email: [Your Email Address]

B. Professional Status and Credentials

I am not a physician, surgeon, psychiatrist, psychologist, physical therapist, or other licensed health care provider in the State of California.

I operate under the provisions of California State law (SB-577) which allows me to provide complementary and alternative health services without a state license, provided I comply with all statutory requirements, including providing this mandatory disclosure form.

C. Education, Training, and Experience

My education and training related to the services offered are as follows:

  • Training Institution(s): [List name of school/institution, e.g., Upledger Institute, School of Natural Health]

  • Certification/Degree: [List certification/degree obtained, e.g., Certified CranioSacral Therapist, Master of Science in Holistic Nutrition, Certification in Reiki Master Level]

  • Years of Experience: [Number of years practicing this modality]

  • Other Relevant Training: [List specific relevant workshops, continuing education, e.g., Pediatric CST, SomatoEmotional Release]

SECTION 2: DESCRIPTION OF SERVICES AND SCOPE OF PRACTICE

A. Description of CranioSacral Therapy (CST) and [Other Modality]

CranioSacral Therapy (CST) is a gentle, hands-on method of evaluating and enhancing the function of the body’s craniosacral system, which is comprised of the membranes and cerebrospinal fluid that surround and protect the brain and spinal cord. CST is intended to support the body’s natural healing processes and is often used to address stress, pain, and dysfunction.

The services provided by this practice are complementary and alternative in nature. They are intended to:

  1. Support general wellness and relaxation.

  2. Enhance the body’s natural self-regulation and self-healing abilities.

  3. Support the reduction of stress and tension.

B. Scope of Practice and Limitations

I do not diagnose, treat, or cure any disease, illness, or medical condition.

  • The services offered are not a substitute for medical diagnosis or treatment from a licensed health care practitioner.

  • I do not prescribe pharmaceuticals or suggest changes to your existing medical treatments or medications.

  • I am not qualified to provide medical advice. Any information provided during a session is for educational and informational purposes only.

C. Client Obligation Regarding Medical Care

As the client, you understand and agree that you must consult with a licensed physician or other licensed health care provider for any physical or psychological ailment that you suspect or know you may have.

SECTION 3: INFORMED CONSENT AND CLIENT RIGHTS

A. Right to Refuse or Terminate Treatment

You have the right to refuse any service or procedure, and you may terminate a session or the professional relationship at any time and for any reason. Your refusal or termination will not result in any penalty or future denial of services.

B. Expected Outcomes, Risks, and Benefits

Potential Benefits (Expected):

  • Deep relaxation and reduction of stress.

  • Improved sleep quality.

  • Enhanced sense of well-being and vitality.

  • Relief from tension-related pain.

Potential Risks/Side Effects:

  • Emotional Release: Deep relaxation may trigger emotional release, which may manifest as crying, lightheadedness, or temporary discomfort.

  • Temporary Symptoms: In rare cases, clients may experience temporary fatigue, headaches, or increased symptoms as the body processes the treatment. These are typically short-lived.

C. Confidentiality and Privacy

All information shared during sessions is strictly confidential. I will not release any information about your sessions or personal data without your written authorization, except where required by law (e.g., in cases of mandated reporting of child abuse, elder abuse, or a threat of serious harm to self or others).

The full details of how your personal and health information is collected, stored, and protected are contained within the separate Privacy Policy document, which you are encouraged to read.

SECTION 4: FINANCIAL AND ADMINISTRATIVE POLICIES

  • Fees: The current fee for a [Session Type/Duration] is $[Amount].

  • Payment: Payment is due at the time of service.

  • Cancellation Policy: [Briefly state your policy, e.g., 24-hour notice required to avoid a full session charge.]

CLIENT ACKNOWLEDGEMENT

I have read and understand the contents of this Disclosure and Informed Consent form. I have had the opportunity to ask questions, and any questions I had were answered to my satisfaction. I understand the practitioner’s credentials, the nature of the services, and the fact that the practitioner is not a licensed physician. I voluntarily consent to receive CranioSacral Therapy and/or [Other Modality] services from [Your Name].

  • Client Name (Printed): _______________________________________

  • Client Signature: _______________________________________

  • Date: _______________________________________