(Confidential for practitioner use only)

Internet form – recommended option

This form will be sent online once you have completed it and given your consents. This will give Mr. Bérard the opportunity to review it before the meeting and will save a lot of time during the first meeting. Once the form has been sent, you will receive a copy by email.

If you are unable to complete the form in one go, you can click the link at the end (Save and continue later) and the form will be saved. You will receive a secure link so you can return to it later to complete it.

Manual Option – Form.pdf

However, if you absolutely do not want to fill out a form online or have problems filling it out, you can choose the option to fill out and print the .pdf form and bring it with you to your first meeting. Click here to access the form. (233kb)

Formulaire individuel (English)

Individual form

Please fill out the form and answer all the starred boxes.

If you receive an error message, the form cannot be sent so check if all the starred boxes have been checked, including the consents and the answer to know if you want to be on my mailing list.

Thank you for taking the time to share this valuable information.


Emergency contact


Family doctor


Therapist


Daily consumption: (In units)


Emotional/Psychological:


Immune system (type)


Endocrine


Neurological (type)


Muscular-skeletal


Ear / Nose / Throat


Cardiovascular


Respiratory


Digestion


Urinary


Reproduction


Childhood illnesses


Others


Relationship with your father


Relationship with your mother


Consent for individual energy treatment

(Please read the following information and sign the form.)

 
 

 

 


Consent to processing

Welcome to My Support Practice
This document contains important information about my approach and policies. Please read it carefully and note any questions you would like to discuss with me. Then, sign at the bottom of the page to indicate that you agree with the contents. I am pleased to have the opportunity to work with you.

As a support practitioner, I do not provide medical diagnoses or prescribe medication. My approach is holistic and considers you as a complex, dynamic, and unique being—body and mind—and I serve as a facilitator in your personal process.

My approach involves working with the body and energy field, as well as the consciousness associated with imbalances. I work directly with the energy field and through the body to promote self-discovery and identify what prevents you from fully enjoying life and being in your pure essence. This work is collaborative and requires your commitment to being curious and exploring yourself as we work together.

We will explore factors that influence your state of well-being, such as your health history, sources of stress in your life, attitudes, family, diet, exercise, and relationships.

The energy work technique through hands-on healing balances and recharges your energy field and clears accumulations that can eventually transform into discomfort and illness. This enhances your body’s self-healing potential. I work by laying hands on your body through touch or by working on your energy field above the body. Sometimes, I use sound to dissolve these accumulations. If, at any point, you feel uncomfortable, it is your responsibility to let me know. Taking care of yourself is an important aspect of your return to well-being.

Be aware that this work can bring up strong emotions. Due to the nature of this work, please do not attend sessions under the influence of alcohol and avoid consuming alcohol within 24 hours after the treatment.

Confidentiality

Everything you share is confidential. However, I sometimes discuss clients (without identifying them) with my supervisor or colleagues to support my professional development and better serve you.

By law, confidentiality will not be upheld in the following cases:

  • If you pose a danger to yourself.
  • If you pose an imminent danger to another person.
  • If there is reason to believe that a child or elderly person is being abused or neglected.

Phone and Email

I try to respond to calls as soon as I am available.

Phone and email are not the best methods to address issues or emotions that may arise during a session. I treat any correspondence or calls from you as sacred. I will read the emails you send me, but I may not necessarily reply. I do not provide consultations by email unless we have made prior arrangements to do so.

Please be aware that emails are not confidential and can be intercepted on the internet. I cannot be held responsible if the information contained in email exchanges becomes public.

Phone calls lasting more than 10 minutes will be billed as a half-session, and those exceeding 30 minutes will be billed as a full session.

Provisions Related to the Privacy Act (Law 68)

You have shared personal information with us. Following the implementation of Law 68, and unless otherwise notified by you, we consider that you consent to our recording in a file all the information you have communicated or will communicate to us, verbally or in writing. Additionally, unless otherwise notified by you via registered letter, we consider your consent valid for a period of five (5) years. Any information provided may be recorded in your file.

Questions

I will be happy to answer any questions you may have, and I encourage you to share your concerns about this work.

Consent and Limits of My Practice

I have read and understood the information presented here by Roland Bérard. I further understand that he does not offer psychotherapy services, that his services are not medical examinations or diagnoses, nor a substitute for medical treatment, and that nothing said during the session should be interpreted as such.

All my questions have been answered to my satisfaction.

I consent to Mr. Bérard reading my energy field remotely before treatments.

The client acknowledges that they are presenting themselves under their true name, in good faith, and for no other purpose than to receive natural therapy care.


Cancellation, Late Payment and Returned Check Policies

Cancellation of an Appointment
Please provide at least 24 hours’ notice (preferably 48 hours) in advance if you need to change or cancel your appointment. Otherwise, the full payment for the session will be required and must be paid before scheduling the next session. In cases where illness or severe weather makes travel dangerous, it is always possible to work remotely via telephone or Skype.


Late Arrivals
If you arrive late for your appointment, we will use the remaining time; however, the full payment for the session will still be required.

The first session lasts approximately one hour (1h), and subsequent sessions are 50 minutes. If you believe you need more time, it is possible to schedule a longer appointment in advance, and the cost will be adjusted accordingly.


Payments
Payments are due at the end of each session and can be made at the office by check or cash. Payments can also be made in advance through my website using Interac or PayPal.


Returned Checks
A fee of $15 applies to checks returned by your financial institution.


Consent and Limits of My Practice
I have read and understood the information presented here by Roland Bérard. I also understand that his services do not constitute psychotherapy, a medical examination, diagnosis, or a substitute for medical treatment, and nothing said during the session should be interpreted as such. All my questions have been answered to my satisfaction.


I agree that Mr. Bérard will read my energy field remotely before the treatments. The client acknowledges that he presented himself under his real name, in good faith and for no other reason than that of natural therapy care.