Informed Consent

for

Emergent Hippie Collaborations

Mary Kalbach - Post Traumatic Growth Coach,

Embodied Mindfulness Coaching

https://www.marykalbach.com   (01)443.417.6582  support@marykalbach.com


 

About Me and My Coaching Practice:

 

I function within Emergent Hippie Collaborations as a Post Traumatic Growth Coach and Embodied Mindfulness Coach.  I am certified as a Clinical EFT Practitioner with a specialty in trauma from EFT Universe and also as a Certified Mindfulness Mentor with the Mindfulness Mentoring Institute in Australia.  I am in training as an ABE certified practitioner of  Psychodrama, Sociometry and Group Therapy with over 500 hours of training accumulated toward my Certified Practitioner status.  I am certified in Level 1 Training in the Therapeutic Spiral Model (TSM) of Psychodrama and have training as a Trained Auxiliary Ego and Assistant Team Leader  for TSM.  I hold a bachelor’s degree from Bucknell University in Theater and Religious Studies and a Master’s degree from Brown University in Theater History and Theory.  I am equipped with many skills in these areas of training which include embodiment coaching, mindfulness coaching, psychodramatic and sociometric techniques, Clinical EFT “Tapping”, working within the energetic “field”, basic movement and breath work, working within the Trauma Survivors Internal Role Atom, and “sandtray” type experiences for both individuals and groups of individuals who have experienced trauma.  I specialize in collaborating with individuals who have experienced significant childhood trauma and varying levels of dissociation and symptoms of dissociative disorders.  

 

I am a member of the American Society of Group Psychotherapy and Psychodrama, the Association for Comprehensive Energy Psychology, and insured through the Energy Medicine Professional Association. I adhere to the ethical code of all organizations, which place client safety at the forefront of all coaching practices.

 

Scope of Practice:

 

I am not a licensed counselor, therapist, or mental health practitioner.   I cannot and will not diagnose, treat, or cure any physical or mental health condition. I am conversant in mental health diagnoses found within the DSM-V and may be able to assist you in understanding diagnoses given by licensed practitioners.  Interactions involving diagnosis are solely for educational purposes and not intended as medical advice or as clinical diagnosis.  Any advice that I might offer during a consultation, coaching session, class or communication of any type does not constitute medical advice.  I cannot and will not prescribe or suggest changes to any prescription medication.  Should your needs exceed my ability to serve your needs, I will offer resources and referrals as appropriate. 

 

I am qualified to guide you on your self-directed journey towards Post Traumatic Growth.  1:1 sessions are referred to as Collaborations and truly represent a collaborative effort between your skills and resources and mine.  During the course of our interactions, I may offer psychoeducation and suggestions of resources you may find helpful.  I am trained and qualified to provide you with guidance through Clinical EFT techniques, Mindfulness mentoring, psychodramatic techniques, use of the Therapeutic Spiral Internal Role Atom model and other experiential methods as described above and below.  

 

I hold myself accountable to several licenced, experienced mental health practitioners through regular group and individual supervision sessions.  These are trusted practitioners with many years of experience with experiential modalities and clients with complex diagnoses.  For the safety of myself and my collaborators I maintain a posture of complete openness and transparency with these supervisors and freely share both the challenges and successes I have with my collaborators in order to receive the best guidance possible for both of us.

 

Working within the Energy “Field”:

 

Much of the work I do with collaborators falls under the category of Energy Psychology.  I believe that all humans exist within an energetic environment which I refer to as the “field”.   This field exists both within and around each of us and contains all that chooses to enter it.  This may include pets, children, feelings, ancestral energies, synchronicities, memories, projections, acts of Nature - really anything!  The goal of our work together is to move “stuck” energy and to transform challenging energy into productive energy.  The shifting of internal energy can be challenging work and after our sessions you may find that you are tired as if you’ve engaged in deep labor.  This may show up as physical or emotional exhaustion, thirst, need of “disconnecting” in some way, or a myriad of other responses .  On the other hand, energy shifts may be quite subtle and difficult to detect.  Good self-care and self-compassion before and after our sessions is very important.

 

Use of Mindfulness Mentoring:

 

Contemporary research in trauma recovery indicates that mindfulness plays a key role in development of healthy, restorative thought patterns.  Mindfulness practice is at the core of everything I do with collaborators.  This practice starts with the introduction of the Curious Observer role which functions as an objective observer of the thoughts, feelings, and actions of self with “no shame and no blame”.  Exploration of your core value system and intentional adherence to these values is also a central tenet of mindfulness practice.  Developing a strong mindfulness practice was pivotal to my own recovery from CPTSD and I am firmly committed to providing this guidance for you as a collaborator.  Every other technique described in this document will begin with mindful attention to the self.
 

Use of Clinical Emotional Freedom Techniques (EFT - “Tapping”):

 

I frequently utilize a clinical model of tapping on specific acupressure points while reciting scripts designed to rewire the brain for best outcomes.  This method is referred to as Clinical Emotional Freedom Techniques - or Clinical EFT.  This is a non-invasive therapeutic energy psychology technique in which I tap and recite the scripts and the collaborator mirrors my words and actions.  Use of Clinical EFT may affect your memory of traumatic events and, consequently, may affect the efficacy of your official testimony in a court of law.  It is your responsibility to inform me if the events we are focusing on are the subject of any such official proceedings.  There are no other risks associated with this technique, aside from those described above regarding work in the energy field.  

 

Use of Experiential Therapeutic Techniques:

 

I believe the fastest route to post traumatic growth is through the body which means our sessions will always engage the body through experiences.  There will always be a strong emphasis placed on how you engage and experience your thoughts, memories and feelings within your body.  Experiential techniques I use which help you to do this include psychodrama  (concretizing your experience and making the “covert, overt” through various types of role play) embodied mindfulness (using the curious observer role to notice your thoughts and feelings in your body), Qigong (Chinese yoga), moving to music, body sculpture (creating representative images with your body) and experiencing the body’s response to the “field” in various ways. These experiential techniques have their roots in the Humanistic psychology movement and scientific justification from current theories about the neurobiology of trauma.  

 

Use of Concretization Exercises:

 

In experiential methods, we talk about making the covert overt.  In order to bring those thoughts, feelings, transferences, etc that lie hidden within us to the light, I use methods of concretization.  This means we will be using objects, toys, scarves - really anything our imagination can think of - to become concrete representations of these hidden ideas.  You may find yourself creating a scene with the toys from my toy boxes or mini-stage, gathering objects from your own space to represent your strengths, or interacting with a “furry auxiliary” who can hold a role for you so you can have real, meaningful interactions with the substance of your inner world. While this may feel silly at first, my collaborators generally find this work to be deeply meaningful.  

 

Use of the Psychodramatic Double:

 

A common experience within our collaboration will be my use of the psychodramatic double.  This is a way of helping collaborators find meaning and clarity for your inner experience.  Many times our childhood experiences lacked the meaning making we required to help us understand and regulate our thoughts and feelings.  The psychodramatic double serves to help have those experiences we missed as children.  Throughout our sessions, I will make “I” statements as if speaking from your inner self.  You will always have the choice to accept, correct, change, or reject these statements.  I may also use “body” double or “containing” double statements which are designed to help you feel grounded  and present when experiencing dissociation, or to get you back in your body experience when stuck in your thoughts. 
 

Therapeutic Spiral Model of Psychodrama:

 

The core of our work together will draw from the theory presented in the Therapeutic Spiral Model of psychodrama.  This model uses exploration of internal “roles” (similar to IFS “parts of self”) to gain clarity about how your childhood experiences have informed your internal world and to help you shift away from functioning from internal trauma roles and into roles of post traumatic growth.  These specific roles are detailed in the Trauma Survivors Internal Role Atom (TSIRA) which will be explained to you during the course of our work together.  We will use psychodramatic techniques to move through Prescriptive Roles, Trauma Roles, and Post Traumatic Growth Roles together.  In Emergent Hippie Collaboration group work, group members will be able to hold these roles for one another to the benefit of the entire group.  

 

Confidentiality:

 

Your confidentiality is the most  important part of our work together.  You should feel safe that what is shared in our collaborative sessions stays confidential.  I am committed to maintaining a safe space for our work.  I utilize the Zoom video conferencing platform for our video sessions.  You will receive a zoom link that is your personal link - no other person will have this link. Do not share your link with anyone else.  The waiting room feature will be enabled to assure only you are allowed into our personalized zoom room.  While in session, it is important that you have both your camera and microphone on so that I can continually assess your responses to our work together.  I will not conduct sessions until your safety is assured.  This means that you are in a stationary location and not in the presence of unsafe individuals who may disrupt our work. Please make sure all necessary arrangements are made before each session so that our work can proceed uninterrupted and your full attention can be given to it.  Sessions will only be recorded with the agreement of all those in attendance.  Recordings will be used exclusively for review by myself, my collaborators,  and my supervisors and/or for research purposes as agreed upon prior to the start of the session. 

 

I generally take detailed notes during our sessions. These hand-written notes are kept in a binder and remain in my private home studio space.  I am the only one with access to these notes.  You have a right to review these notes.  For an additional fee of $10/session I am happy to type these up and send them to you via email or through your Casekeepers account.  

 

I communicate with collaborators via email and texting on a regular basis.  These communications often contain personal information about the content of our work.  While I do my best to keep these communications private, I cannot guarantee your privacy through these means.  If you are concerned about the confidentiality of these methods, I have secure channels of communication available upon request utilizing the Casekeepers application.  

 

I hold myself personally accountable to several licensed therapists with a range of experience and therapeutic knowledge.  In order to keep myself within best practices for your safety and mine, I may share information about our sessions with these trainers and supervisors within both group and individual supervisory sessions.  Your information is held confidential by all participants in these supervisory sessions.  Identifying information will not be shared in group supervision sessions. 

 

I am obligated to abide by mandatory reporter statutes for the state of Pennsylvania.  This includes reporting conduct that places you or others at great risk, including self-harm, harm to children, individuals with disabilities, and elderly neglect/abuse.  I will make every effort to discuss this with the collaborator before reporting.  The need to report is a rare occurrence.  

 

There may be times when we find ourselves together in other settings outside of our 1:1 or group work.  Should this occur, I may share that we have a friendly relationship but will not reveal the nature of our coaching relationship or any information gleaned from within our sessions.  This is your information to share and yours alone.  This holds true in any setting where we have mutual connections.  Should you choose to share more deeply about our relationship and/or the content of our work together, I will honor whatever level of confidentiality you model.  

 

There are times when collaboration between myself and your other practitioners can be helpful.  If you would like me to share information with other practitioners, please complete and sign the Information Consent form.  

 

Casekeepers Application:

 

I have a professional subscription to Casekeepers - an online format designed for optimum confidentiality which can be utilized for a variety of purposes.  As a collaborator, you will be given free  access to a personal portal where you can write journal entries, share resources, documents and photos, and communicate with me safely and confidentially.  Within this program we can also create a customized system of “tags” that may help us to communicate more effectively between sessions.  Should you choose to utilize this resource, you have the option to schedule a free one time 1:1 session with a Casekeepers representative to help you understand how to best utilize the features of the program.  The program also has an app for use on mobile devices.  Your use of this program is voluntary and not a requirement of our work together.  There is no fee to you to utilize this resource.

 

Fee Payment and Client Responsibilities:

 

My standard fee for collaborative sessions is $95/session. Should this fee be prohibitive, we can discuss a sliding scale fee.   Since I am not a licensed medical professional,  I am not able to work with insurance companies, although some people are able to utilize Health Savings Account funds for their sessions.  

 

There is an additional $10 fee/session for those desiring detailed session notes from our time together.  This fee is not negotiable. 

 

All billing and invoicing is organized through Paypal.  You will receive an emailed invoice from Paypal at the beginning of each week before your session.  Please be sure to pay your invoice before our session begins.  All international sessions with foreign currency will be billed in American dollars.  Paypal will automatically calculate the currency conversion for you. 

 

There is a $25 cancellation fee for appointments not cancelled within 24 hour notice.  In this case, the cancellation fee will be charged in lieu of the session fee.   Cancellations due to unforeseen circumstances will not be privy to this charge.  Unforeseen circumstances may include - and are not limited to - death in the family, sudden illness of self or family,  family situation requiring immediate attention, or unpredictable dissociative regression that prohibits safe involvement in our work.  I have the final word in what constitutes an unforeseen circumstance.   I am happy to reschedule or cancel appointments with enough advance notice should you become aware of a scheduling conflict.   Please communicate about changes in the schedule via email to support@marykalbach.com or through your Casekeepers portal so that we both have a record of our communication. 

 

I will do my best to begin the Zoom conference at the exact time of our scheduled appointment.  I will wait for 15 minutes before discontinuing the session if you have not yet arrived.  After 15 minutes, the session will need to be rescheduled and may be privy to the $25 fee. I may make mistakes in timing or scheduling.  You will never be penalized for mistakes made on my part.  

 

Sessions will generally run an hour long and the fee is the same no matter how much time we spend in session together.  Since energy work can be exhausting, we may complete our work after 20 minutes or we may require a few extra minutes past the hour.  I will take the time to assure you are feeling safe enough to complete the session and return to your environment.

 

Should you engage in group work through Emergent Hippie Collaborations, you have a responsibility to maintain the confidentiality of other group members.  Your own experience belongs to you and of course may be shared with whomever you choose.  However, the specific experiences of others are not yours to share.  The identity and experience of other group members should be closely guarded and honored with your confidentiality, as they should do for you.  

 

You are responsible for your own self-care.  This includes before and after sessions, as well as in between sessions.  I am not equipped to handle emergencies or crisis situations.  Should you need immediate assistance contact your mental health provider, go to a local ER, call 911, or contact the suicide hotline at 1-800-273-8255 in the US. In countries outside the US, help can found at http://www.suicide.org.

Collaborator Rights:

 

Your experiences during our sessions are confidential, and you have a right to view your files upon written request. Confidentiality is subject to the following exceptions: 1. You may instruct me to release information to other health care practitioners in writing. 2. I may release information if subpoenaed or otherwise legally obligated or reasonably allowed to do so (Including circumstances where there is clear and imminent danger to yourself or another person). 3. Your confidential personal file is kept in a secure location and is retained for 4 years after you suspend services after which time all information will be destroyed in a proper manner. 4. Your confidentiality is always subject to the usual exclusions dictated by state, federal and international laws and regulations.

 

 

ACKNOWLEDGEMENT, CONSENT, CLIENT PRIVACY RIGHTS

 

 I have read and understand the above disclosure regarding the services offered by Mary Kalbach through Emergent Hippie Collaborations. We have discussed the nature of the services to be provided including information that her practice includes holistic complementary and integrative energy based therapy. I understand that she is not a licensed physician and that her services are not licensed by any entity. I understand it is my responsibility to maintain a relationship for myself with a medical doctor and/or mental health practitioner, if I so desire. I further understand that Mary Kalbach is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies. I have read and understand the above disclosure regarding privacy policies and confidentiality, and that experiences during these sessions are confidential, but subject to the usual exceptions governed by laws of the State of Pennsylvania and other federal and international laws and regulations. 

 

I agree to provide a complete medical and psychological history as requested by Mary Kalbach.  

 

Except in the case of gross negligence or malpractice, I or my representative(s) agree to full release and hold harmless Mary Kalbach from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). I have been informed that Mary Kalbach will neither diagnose nor prescribe for any condition that I might have nor does she make any specific claims regarding results from the sessions that I receive. 

 

My questions have been answered to my satisfaction regarding Mary Kalbach’s background, a Post Traumatic Growth Coaching session, and what I might expect from this session. I fully consent to use the services offered by Mary Kalbach by signing below: 


 

Signed: _____________________________________________ Date: _____________ 


 

Print Name: ______________________________________ 


 

Address: ______________________________________ 


 

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