I voluntarily consent to an Intensive with Dr. Julie Lopez. I understand that the healing arts are not an exact science and that no guarantees are being made as to the result or evaluation of this intensive.

More specifically, I understand that I am electing to participate in a short-term intervention of an intensive customized nature (the “intensive”). I also understand that the intensive is designed to re-wire data stored in implicit memory, which is a part of my system that resides beyond logic and explicit data. As such, I understand that targeting one current day issue may unearth a whole network of data stored in implicit memory that, by definition, cannot be predicted ahead of time because it is data stored in my unconscious mind. Should data that is detrimental to my well-being be exposed, I understand Dr. Julie will do all in her clinical expertise to assist in my system management, my self management and improving my body’s tolerance for this data. However, ultimately, due to the short term nature of the intensive, I understand and agree that Dr. Lopez will not be responsible for any therapeutic needs that may be exposed in our work, and will not become my therapist at any time during the intensive.

I am aware that I am an active participant in my wellbeing and I share the responsibility for the treatment process to follow the intensive. Through the process of the intensive, I am working toward changes and recognize that I may experience many different and intense feelings as a part of this process, some of which may be painful. I also understand that when I make changes in myself, I may experience changes in other areas of my life (i.e. family, work, and social life may be affected). Every change potentially has both positive and negative effects.

I understand that it is my responsibility to follow up with my primary coach/therapist, as identified and instructed in the Coach/Therapist Agreement for Post-Intensive Integration, after my intensive. I also understand that I can contact the nearest public emergency mental health service if I am unable to contact my primary coach/therapist or their designee.

I further understand that Dr. Julie will have a post-intensive consultation with my primary coach/therapist within 1 week after the post intensive consultation, to include Dr. Julie’s clinical recommendations for follow up work if recommended. The consultation will be via email using Dr. Julie’s secure server or directly scheduled phone call. I understand that our work will be kept strictly confidential with the exceptions of legal limitations on confidentiality including professional and supervisory practice, and except for consultations between Dr. Julie and my primary coach/therapist, as instructed in the attached Health Information Release Form.

Within one week after the dates for the intensive are confirmed, Dr. Julie will initiate a pre-intensive consultation with my primary coach/therapist. I understand that the pre-consult may indicate that the intensive format is not going to be a good fit for me. This determination will be made solely by Dr. Julie based on the pre-consultation. Should it be determined that an intensive is not available to me, I understand my reservation with Dr. Julie will be canceled and my full payment will be returned minus the non-refundable $350 consultation and processing fee. I also understand if my intro session has already been conducted at the time a determination is made not to move forward with the intensive, $500 will also be deducted from my return payment.

Because of the extremely short-term nature of the work together, Dr. Julie will not be providing diagnostic codes nor procedural codes for our work. This means the intensive will not be covered by insurance, and I will be responsible in full for intensive payment.

This form has been explained to me, and any questions I had have been answered. My signature below confirms that I fully understand the information set out above, including the limits of the intensive and what will be required of me for therapeutic follow up, as well as my responsibility for payment for the intensive, and with that understanding my signature below indicates my choice to engage in the intensive.

I hereby instruct Dr. Julie Lopez to release my protected health information to my primary coach/therapist for the purpose of their consulting together in connection with the proposed time-limited Intensive I will participate in with Dr. Julie, including for pre- and post-intensive consultations.

Primary Coach/Therapist to receive my protected health information:

The information I wish to have released to Dr. Julie includes all records related to services provided at any time, including but not limited to, psychotherapy, coaching and background interview notes, physical and mental medical history, and any information about drug/alcohol abuse.

I understand the following:
A. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
B. Information released in response to this authorization may be re-disclosed to other parties.
C. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any electronic version, copy or photocopy of this authorization shall authorize you to release the records requested herein. This authorization will expire 1 year from the date it is signed.

I understand that before my intensive can take place, I will need to have a coach/therapist that is available to do any integration work if wanted/needed.

I understand that payment of the full cost as set out above is due to Dr. Julie Lopez at the time an intensive is scheduled, in the form of Stripe payment. I further understand that intensives are not covered by insurance, and I am responsible for all charges. Statements showing dates of visits, charges and payments will be provided upon request. Should legal action/collections become necessary, I understand that the collection/legal fees will be my responsibility.

I understand that once scheduled a full refund of my payment is possible only when cancellation is made at least 30 days in advance of the scheduled intensive. A 50% refund will be given for cancellation at least 14 days before the scheduled intensive. No refund is available for cancellation less than 14 days before the scheduled intensive, with no exceptions. I understand that applicable deductions to the refund will follow the fees outlined on the table below.

I furthermore understand that there are different cancellation/no show fees based on how far along I am in the process of the intensive package as outlined on the table below.

Situation	Description	Fee
Pre-consultation post payment	Intensive has been processed but no sessions or consultations have been conducted.	$250 (administration)
Post pre-intensive session	It is determined in the pre-intensive session with Dr. Julie that we will not be moving forward.	$610 (session + administration)
Missed appointment	Less than 48 hours is provided barring emergency situations.	$360
Post pre-intensive and integration coach/therapist consultation	It is determined after integration coach/therapist consultation + administration not to move forward with the intensive.	$800 (session consultation + administration)

As an intensive client of Dr. Julie, I acknowledge and accept full responsibility for this account and guarantee payment of all charges against this account to Dr. Julie Lopez.

I understand that time-limited intensives with Dr. Julie Lopez is billed at the rates listed below.

I understand this intensive package includes a pre-intensive as well as a post-intensive debrief. Furthermore, the primary coach/therapist identified through the completed agreement maybe consulted pre or post intensive as needed for integration support