Well of Life Center for Holistic Healthcare

Splankna Therapy New Client Form



1st Marriage:

2nd Marriage:

Other Marriages/Children:



Statement Of Confidentiality:

The Client-Therapist relationship offers confidentiality in so far as allowed by the laws of the State of Pennsylvania. Under certain conditions, the right to confidentiality is necessarily violated. Those conditions include the potential for suicide or homicide on the part of the client. Likewise, when there is reason to suspect that physical or sexual abuse has occurred to a child or an elderly person, the therapist is required by law to report the situation to the Department of Human Services, division of Child Protective Services.
Please click HERE to read our Client Informed Consent and Disclosure Statement. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Consent and Disclosure Statement.

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