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Hello, my name is Carolyn O’Byrne and I am a colon hydro-therapist, life coach, and author.
My training and experience directs me to be able to support many emotional and physical concerns.
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 and federal laws and regulations.
ACKNOWLEDGEMENT, CONSENT, CLIENT PRIVACY RIGHTS:
I have read and understand the above disclosure regarding the services offered by Carolyn O’Byrne. We have discussed the nature of the services to be provided. I understand that she is not a licensed physician and that her services are not licensed by the state of Alabama.
I understand it is my responsibility to maintain a relationship for myself with a medical doctor, if I so desire. I further understand that the above named 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 Alabama and other state or federal laws and regulations. I or my representative(s) agree to full release and hold harmless Life Coach Service, LLC and/or Carolyn O’Byrne 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 my life coach 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. I fully consent to use the services and agree to the privacy and disclaimers offered by Life Coach Service, LLC by filling out this form and using my name in this form as my signature.