Rachel Ortlieb, CBT

Biofeedback Agreement / Informed Consent

 
I understand Rachel Ortlieb is a Certified Biofeedback Technician (CBT) who uses the EPX biofeedback device which is intended to help me relax so I can manage my stress and pain and improve the quality of my life.
 
A Certified Biofeedback Technician is not a licensed physician or psychologist, and biofeedback services are not licensed by the State of California. Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures. I understand that Rachel Ortlieb will refer me to a properly licensed professional if I need, or if I feel I need, a specialist to diagnose, treat, counsel or cure me of anything.
 
I understand that I am responsible for my own health, healing and wellbeing. I also understand I can heal myself. I further understand Biofeedback Technicians are not a substitute for adequate medical care and I intend to remain under the care of my primary healthcare provider.
 
I understand biofeedback may be contraindicated for me if I have a pacemaker. I choose biofeedback training even though it may turn my pacemaker off because I am convinced biofeedback can improve my health. I accept the risks involved and hold Rachel Ortlieb harmless for any adverse effects I may suffer or endure.
 
I understand Rachel Ortlieb will keep all information she learns about me completely confidential unless I release her in writing or as required by law.
 
I understand that if I have, or if I think I have, a medical concern, condition, disease, disorder, issue or symptoms, Rachel Ortlieb will help me reduce any related stress and refer me to a licensed chiropractic, medical or osteopathic physician for further assistance.
I also understand if I have, or if I think I have, a psychological or emotional concern, condition, disease, disorder, issue or symptoms, Rachel Ortlieb will help me reduce any related stress and refer me to a licensed counselor, psychologist or psychiatrist for further assistance.
        
I acknowledge that I have read and understand this form. I agree to allow Rachel Ortlieb to help me learn to heal myself using the natural healing techniques and modalities herein listed.