2. Consultation Agreement

This form gives you information on what my homeopathy consulting is and is not; payments; communication; and serves as your formal request to consult with me.

Please be notified of our Privacy Policy. Printable forms are available upon request.

Let me know if you have any questions.

Name of Client

First Name

Last Name

Disclaimer & Terms

Mary Sheiko and Mary Sheiko Homeopathy LLC will be used interchangeably. Be aware that: the goal of the homeopath is to help strengthen the constitution and thereby raise the general level of well-being of the client through the gentle prompting of the vital force by homeopathic remedies. Consultations include a comprehensive intake that carefully evaluates the whole person. Clients will be asked about their physical, mental, emotional, and spiritual health; temperament, personal habits, likes/dislikes; unique outlook on life, as well as life experiences. Providing this information will allow the homeopath to understand each client as an individual and to provide the most holistic education and recommendations about homeopathic remedies. I acknowledge that Mary Sheiko is not a doctor and neither she nor Mary Sheiko Homeopathy LLC provides medical advice or services but, rather, provides private consulting for individuals wishing to use homeopathy for themselves or their dependent This consulting involves information sharing about homeopathy, including suggested remedies, and general wellness. Any of the above used by me, the consultee, or my dependent is considered self-treatment and is my sole responsibility. Furthermore, homeopathic consulting and advice is not medical care. Homeopathy is complementary to regular medical care or emergency care. It is not a replacement for seeing a doctor for regular medical care including emergency care. I acknowledge that Mary Sheiko cannot diagnose, prevent, treat, mitigate, or cure disease. She makes no claim to my results. No homeopath can guarantee improvements to my overall well-being. My Responsibility: Providing information during consultations regarding my physical, mental, emotional, and spiritual health; temperament, personal habits, likes/dislikes; unique outlook on life, as well as life experiences, will allow Mary Sheiko to better understand me or my dependent as an individual and thereby provide the best recommendations for homeopathic remedies and education about remedies. I am responsible for seeing my physician(s) for regular medical care and emergency care. I am responsible for contacting my physician(s) about any health concerns I may have or come to have. I am recommended to notify my doctor about any changes I choose to make to my health or healthcare routine. Our consults will include discussion about the client information shared as described above; homeopathy, including possible remedy recommendations; and general wellness. Any of the above information used by me is considered self-treatment and is my sole responsibility for myself or my dependent. It is important that I tell Mary Sheiko about any medical diagnosis, prescription medications, or supplements including herbs that I take as it may impact her awareness about the information she shares with me, as well as the possible remedies I share with you as well as the recommendations she may give. I will note the time-frame recommended for each remedy and continue only as long as recommended or check with Mary Sheiko before continuing. I acknowledge that Mary Sheiko is currently a homeopath in training.

Consent to Consult

I am over 18 years of age and have voluntarily chosen homeopathic consulting for myself and/or my dependent. I understand that Mary Sheiko is providing homeopathic consulting as described above through Mary Sheiko Homeopathy LLC. I am aware that this is not care given by a medical doctor and that Mary Sheiko is not a licensed health care practitioner. (see Disclaimer.) I recognize that Mary Sheiko does not keep medical records since she is not a medical provider. However, I grant her express permission to take notes during our consultation which may contain information about my physical, mental, emotional, and spiritual life, and I understand that this may be kept on a cloud drive. Furthermore, I understand that any approved communications (see Communications Consents) may contain information in the aforementioned areas. I agree that the use of Mary Sheiko and Mary Sheiko Homeopathy LLC’s services and the website MarySheikoHomeopathy.com is voluntary and expresses: 1. Sole and full responsibility for the consequences of applying any information gained by Mary Sheiko or Mary Sheiko Homeopathy LLC's services or said website and to hold harmless for said use; 2. Any and all claims are governed by law and nor legal codes, acts, or statues, and may be settled in private arbitration and me and my heirs, administrators, or assigns give up the right to sue, file a complaint against Mary Sheiko or Mary Sheiko Homeopathy LLC in court or seek trial by jury; 3. Trade for service is due at the beginning of each appointment or as described (see Payments and Communications below) and is not returnable; 4. I am not an agent or representative for any governmental or non-governmental agency or organization whose purpose is to enforce legal code, act, or statute where no man or woman has been harmed, or to carry out any mission of entrapment or investigation, as this will be considered trespass by way of barratry with immediate liability to pay compensation under this agreement in the amount of $250,000 (USD) plus $100 USD/minute said trespass continues.

Confidentiality

I understand that all information disclosed is confidential and may not be revealed to anyone without written permission, except when disclosure is required by law. (Disclosure may be required in circumstances such as: a reasonable suspicion of child or elder abuse or a reasonable suspicion that a client presents a danger to him/herself or others.) This serves as written permission authorizing discussion of my case with other homeopaths and/or health care professionals should the need arise for purposes of remedy recommendation and/or case analysis necessary or if my best interest is served by such a consultation. In doing so, my right to privacy will be protected by withholding identifying information.

Payments

In consideration of services to be rendered, the undersigned agrees to pay the consultant, in accordance with their regular rates and terms, for the services rendered. Fees are as listed at: https://tidycal.com/marysheikohomeopathy. However, other packages and discounts may be offered at an agreed upon rate in oral or written communication with the client or prospective client. All payment is due in USD at time of service. Payments may be made the payment platform linked through Mary Sheiko / Mary Sheiko Homeopathy LLC's booking platform or through another service that Mary Sheiko and I have mutually agreed upon verbally or in writing prior to booking. Consultations exceeding the allotted appointment time will be charged $25 USD per 15 minutes. Mary Sheiko charges a $35 USD fee for no-shows (15 minutes past start time) and for appointments canceled within 24 hours of appointment date for non-emergency reasons. If I decide to cancel a session after I have paid, I will reschedule within three days, unless otherwise arranged with Mary Sheiko, or there will be a 10% processing fee or a minimum of $20 USD for payments under $200 USD to cover administrative time and payment platform fees incurred by Mary Sheiko. These fees do not include homeopathic remedies. After your consultation, Mary will share information on where you may order them, if you do not already have a resource in place. Mary Sheiko does not keep medical records. I may request dates of appointments and remedy recommendations for an additional fee which will be determined upon request. However, it is recommended that I track these things.

Communication Consents

I consent to the following communications (Emails and Virtual Meetings required):

Emails (required)

Virtual meetings (required)

Text messages

Voicemails

Phone calls

Acknowledgement

I acknowledge receipt of the Consultation Agreement including Disclaimer & Terms, Consent to Consult, Confidentiality, Payments, and Communication Consents. Finally, I request that Mary Sheiko perform consultation for the intended purpose of my own self-treatment with homeopathic remedies for myself or my dependent.

Client Signature (or Legal Guardian)

Your Digital Signature is Your Consent for Yourself or Your Dependent

Date

YYYY

Pre-Consultation Forms

Intake Form

2. Consultation Agreement