Health Questionnaire

For Initial Consultation with Michelle Haley DMH, DHHP, BCST
Doctor of Medical Heilkunst, Practitioner Diploma in Homeopathy & Heilkunst, Diploma Biodynamic Craniosacral Therapy

I understand that Michelle Haley is not a licensed medical practitioner. I have freely chosen to use the services offered by Michelle Haley and agree to be personally responsible for the consultation fees of Michelle Haley, in connection with the services provided to me, and that these services provided by Michelle Haley may not be covered by my health care insurance plans but may qualify for coverage under an employer health spending account.

I the client, give my consent to Michelle Haley, to keep a file with my personal information, whether given orally, in writing or electronically. My typewritten signature below provides consent for Michelle Haley, to gather in a secure confidential file from now on, all information that I provide. Unless I instruct otherwise in writing, this consent will extend for seven years from the last information provided.

I the client, agree that if at least 24 hours notice is not given for canceling or rescheduling an appointment, the full session fee is due and payable to Michelle Haley unless this appointment can be filled by another client. 

Acknowledgment and Consent to Choose and Receive Services:
I have read and understand the above disclosure.