DISCLOSURE STATEMENT

Megan Eggers Zubaedi MA, CMT, CST, CCSP

www.soulseed.life www.meganeggers.com

Megan Eggers Zubaedi MA, CMT, CST, CCSP

3335 Darley Avenue Boulder, CO 80305

303-570-2033 purplemountainmeg@gmail.com

PROFESSIONAL DISCLOSURE:

1a. My degrees are: Colorado College, BA in Liberal Arts 1998; Naropa University, MA in Somatic Psychology: Body Psychotherapy 2005.

b. I am certified in: Massage Therapy, Colorado School of Healing Arts, 1999; CranioSacral Therapy, Colorado School of Healing Arts, 2000; Somatic Archaeology™, Howling at the Moon Productions, Inc., 2002; Core Synchronism, 2008. I am registered with the Department of Regulatory Agencies as Registered Psychotherapist and as a Massage Therapist. For a more extensive resume of my background and training, please see my Curriculum Vitae on my website.

 

c. I am not licensed in any of these disciplines.

d. Our work together may include use of Energy Work, Cranial Sacral Therapy, Massage Therapy, Kaiut Yoga, facilitated emotional release or trauma resolution, conscious and therapeutic touch, therapeutic Essential Oils, Flower Essences, life-skills, relationship, and behavior counseling, spiritual counsel, or psychotherapeutic process.

You have the right at any time to make requests and suggestions about how I might better serve you. You have the right at any time during hands on work to ask me to stop. Please direct me in better supporting your needs.

 

2. The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of unlicensed individuals who practice psychotherapy and bodywork. Department of Regulatory Agencies, 1560 Broadway, Suite 1350, Denver, Colorado  80202, (303)-894-7766.

3. Client Rights and Important Information:

a. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of therapy (if I can determine it), and my fee structures. Please ask at any time if you would like to receive this information.

b. You can seek a second opinion from another therapist or terminate therapy at any time. If the work we are doing is not meeting your needs, I am happy to provide referrals to other therapists.

c. In a professional relationship (such as ours), sexual intimacy between client and therapist is never appropriate.

d. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is registered psychotherapist; I uphold the professional standards, of a registered psychotherapist which are more rigorous than the professional standards of massage therapists and bodyworkers. The information that is shared in our therapeutic container is legally confidential, the therapist cannot be forced to disclose the information without the client’s consent. Information disclosed to a registered psychotherapist is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person whom the testimony sought relates. There are exceptions to the general rule of legal confidentiality. These exceptions are listed in the Colorado statues (C.R.S. 12-43-218). You should be aware that provisions concerning disclosures of confidential communications shall not apply to any delinquency or criminal proceedings, except as provided in the section 13-90-107 C.R.S. There are exceptions that I will identify to you as the situations arise during therapy.

e. There may be times when I may consult with a professional supervisor, or my professional supervision group about issues raised in our work together. Your confidentiality is still protected during consultation and supervision by the professional(s) and myself. Signing this disclosure gives me permission to consult as needed to provide, enhance and support the professional services you are receiving

f. If I believe that the issues that arise in our work together are above or beyond my level of competence, or outside my scope of practice, I am legally required to refer, terminate or consult.

CONSENT

I understand that Megan Eggers Zubaedi practices an integrative modality that bridges bodywork and psychotherapy, a method that has not been validated by the Department of Regulatory Agencies, or governing boards of Psychotherapy or Bodywork.

I recognize that this work is intended to be transformative and that things may change as a result of pursuing this work. This change can sometimes precipitate periods of physical, emotional or psychological discomfort. Megan will do the best, within her scope of practice, to support you, and at times the addition of other health care providers is encouraged.

I understand that the nature of this work is evocative and that there is a possibility that I will recover memories of things that I have not previously remembered.

I understand that Megan is not qualified to diagnose, prescribe, prognosticate or evaluate physical or mental imbalance of any kind and that anything offered in the realms of physical or mental health or development is a only suggestion.

I understand that Megan’s office is located at her private residence. I will be considerate of personal boundaries and not come to Megan’s house outside of the session time.

I agree to honor Megan’s 24 hour cancellation policy and will compensate Megan if an appointment is cancelled within less than 24 hrs.

I agree to take responsibility for myself and my healing process, communicating with Megan about concerns that may arise and seeking support where it is needed.

SIGNATURE:

By signing below you acknowledge your understanding and agree to all the terms discussed in this consent form and the professional disclosure statement. If you have any questions or would like any additional information at any time, please feel free to ask!

I, (print name) ________________________________ have read the information in this document and understand my rights as a client.

_________________________________________ ___________________

Client signature Date

_________________________________________ ____________________

Megan Eggers Zubaedi Date

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