THERAPEUTIC ARTS REGISTRATION FORM

THERAPEUTIC ARTS REGISTRATION / BOOKING FORM

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NAME *

First

Last

ORGANIZATION *

PHONE NUMBER *

EMAIL *

WHAT PROGRAMS OR SERVICES ARE YOU INTERESTED IN ? *

CREATIVE WELLNESS ONE - TO - ONE (VIRTUAL) CREATIVE WELLNESS THROUGH THE LENS: SHIFT PROCESS CREATIVE WELLNESS THROUGH CONNECTIONS CREATIVE WELLNESS OPEN STUDIO PROGRAM CREATIVE WELLNESS SUBSCRIPTION

CONFIDENTIALTY
In my role as Therapeutic Arts Practitioner I will keep confidential what is said and shared both verbally and visually. I will not keep confidential any statements that are expressed or images presented that indicates you or someone else is at risk of being harmed.

CONFIDENTIALITY ISSUES *

YES, I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT ABOUT CONFIDENTIALITY NO, I HAVE QUESTIONS ABOUT THE ABOVE STATEMENT AND WOULD LIKE TO DISCUSS THIS FURTHER.

DISCLAIMER
As a Therapeutic Arts Practitioner I work within a scope of practice in which I do not provide art therapy or counselling services. The therapeutic arts programs and services I do offer, have been designed to promote self - expression, stress reduction, personal growth and general mental wellbeing. These therapeutic arts programs and services are provided in a safe, confidential therapeutic space both virtually and in person. For art therapy and counselling needs outside of this scope of practice, I can provide contact information for Certified Art Therapists as well as other professional mental health practitioners.

DISCLAIMER STATEMENT *

YES, I HAVE READ AND UNDERSTAND THE ABOVE DISCLAIMER. NO, I HAVE FURTHER QUESTIONS ABOUT THE ABOVE DISCLAIMER.

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