(Confidential, for practitioner use only)

Internet intake form – recommended option

This intake form will be sent by internet once you have completed it and filled out the consents. This will give Mr. Bérard the opportunity to get to read it before your RV and will save a lot of time at the first session. Once it has been sent, you will receive a copy by email.

Manual option – .pdf form

However, if you absolutely do not want to fill out a form that will be sent by internet or you have problems filing it out, you can choose the option of filling out a .pdf form, print it and take it with you to your first session.
Click here to access this form. (233ko)

Formulaire individuel english

  • Phone:
  • Emergency Contact:
  • Family doctor :
  • therapist:
  • Daily consumption (in units):
  • Emotional / Psychological:
  • Auto-immune (type):
  • Type
  • Endocrine:
  • Neurological (type):
  • Muscular-skeletal:
  • Type
  • Ear / Nose / Throat:
  • Cardiovascular:
  • Respiratory:
  • Digestion:
  • Urinary:
  • Reproduction:
  • Type
  • Childhood diseases:
  • Other:
  • (Ex .: Separation, divorce, depression, loss of people by death
    or other significant event)
  • (religious training, common practice, development)
  • Relationship with your mother:
  • Relationship with your father:
  • Consent to an individual energy treatment

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

  • Consent Form for Treatment

    Welcome to my practice of support intervention. This document contains important information on my work approach and my policies. Please read it carefully and make note of any questions you may want to discuss with me and then sign it to indicate that you are in agreement with the contents. I am very happy that we will be working together.

    As a support interventionist, I do not perform medical diagnoses nor prescribe treatment. My approach is holistic, focusing on you as a complex, dynamic, unique being – body, mind, and spirit – and I serve as a facilitator in your personal process.

    My approach involves working with the body and the energy field, as well as the consciousness associated with imbalance. I work directly with the energy field and through/by the body to help you discover what might be preventing you from fully enjoying life and being in the full essence of who you are. The work is collaborative and requires a commitment on your part to be curious and to study yourself as we work together.

    We may explore areas that influence your state of wellbeing, such as your health history, life stressors, your attitudes, your family history, diet, exercise, and relationships.

    The hands-on energy work balances, clears, and charges your energy field and removes stagnant energy accumulations that eventually lead to disease or dis-ease. This enhances your body’s natural healing potential.

    At times I will touch your body, and at other times I may work with your energy field off your body. I may also use sound to free up blocks. If at any time during the session you are uncomfortable, it is your responsibility to inform me. Self-care is an extremely important part of your healing process.

    Please be aware that the work may bring up strong emotions and powerful feelings. Due to the nature of this work, please do not come to the session under the influence of drugs or alcohol and I recommend that you refrain from using alcoholic beverages for 24 hours following your session.

    Confidentiality
    Your sharing is always kept confidential. I do, however, discuss clients (without identifying them) with my professional supervisor or professional peers for the purpose of my continuing professional development and to help serve you better as a client.

    According to the law, confidentiality will not be respected in the following cases:
    • If you present a danger to yourself;
    • If you present an imminent danger to another person;
    • If there is reason to believe that child or elder abuse or neglect is present.

    Telephone and email
    I try to return phone calls as soon as I can.

    Telephone and email are not the best way to deal with issues or feelings that are best brought up in the container of the sessions. I consider and hold sacred any correspondence and telephone calls from you. While I will read the emails that you send me, I may not respond to all of them. I do not do consultation by email unless we have a prior agreement to doing so.

    Please be aware that email is not confidential and may be intercepted while travelling on the internet and I cannot be responsible for any information that might become public in email that you send me or an email response that you get from me.

    Telephone consultations exceeding 10 minutes will be billed as half of a session and consultations exceeding 30 minutes will be billed as a full session.

    Information relative to the law on protection of personal information in the private sector (bill 68)
    You have given us information relevant to your personal file. Following the enactment of Bill 68, unless otherwise indicated by you, we consider that we have your consent that we indicate in our files any information that you may have given us, verbal or written. Also, unless we have had official notification from you by registered mail, we consider that your consent is valid for a period of five (5) years. A record on file may be kept of any and all information given, whether written, oral or otherwise, from now on.

    Questions and Concerns
    I am most happy to answer questions regarding my services, and I also encourage you to express any concerns that you may have.

    Consent and Limits of Practice
    I have read and understand the above information provided by Roland Bérard. I further understand that he does not offer psychotherapy, medical examination or diagnosis, a substitute for medical treatment, and that nothing said or done during the course of the session given should be interpreted as such.

    Any questions have been answered to my satisfaction.

    I accept that Mr. Berard does a reading of my energy field by distance before our session. I confirm that I am presenting myself in my own name, in good faith and for no other reason than obtaining a natural therapy treatment.

  • Policies for Cancellation, Lateness and Returned Checks

    Cancellation of an appointment
    I require that you advise me within a minimum of 24 hours (preferably 48 hours) in advance of a change or cancellation for an appointment; otherwise the full payment of the session will be due and must be paid prior to continuing treatments. In the event of illness or inclement weather that would make travel dangerous or impossible, it is always possible to work by phone or Skype.

    Lateness
    If you are late for an appointment, we will use the time that is remaining in your scheduled time slot; full payment will still be due.

    The duration of the initial session is approximately one (1) hour and the subsequent sessions are 50 minutes. If you feel you need more time in a session, it is possible to schedule a longer session ahead of time; the fee will be adjusted accordingly.

    Payment
    Payment is due at the end of each session and can be made by check or cash at the office or ahead of time from my web site by email transfer from your bank account using Interac, or by credit card using Paypal.

    Checks returned by the bank
    There is a $15 charge for processing checks returned by the bank.

  • I accept that Mr. Berard does a reading of my energy field by distance before our session. I confirm that I am presenting myself in my own name, in good faith and for no other reason than obtaining a natural therapy treatment.