Intake Form

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Name*
First Name Last Name
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Have you had COVID 19? (Face-to-Face visits only)*

LIABILITY DISCLAIMER

Before booking your consultation, it is important to read these terms and conditions. Booking your session indicates that you have read and agreed to the terms and conditions.
GENERAL PRACTITIONER:
Kim Barden also recommends that you consult with your doctor, or mental health advisor, before making an appointment especially if you have issues with anxiety and depression. BWRT® is not intended as a substitute for medical diagnosis or treatment. Also, please do not stop or alter any treatment you are currently receiving without the prior consent of your doctor or mental health advisor.
CONTACTING YOUR GP:
Kim will always attempt to seek your permission before writing or making contact with your GP, plus provide you with a copy of any correspondence:
· when Kim suspects a child, elderly person or dependent adult abuse.
· when the client has directed the therapist to share information about their case.
TRAINING:
Kim Barden is a MIBWRT(Adv)® Practitioner and Hypnotherapist. Kim regularly updates her skills and knowledge on the latest developments of BWRT® and Hypnotherapy through online and face-to-face courses to provide the best possible care and opportunity for positive change. Kim uses client centred therapy as the ability to change remains within the client and as everyone is an individual there is no therapy nor therapist in the world suitable for everyone.
No therapist should, therefore, take credit for positive change or lack thereof so no guarantees for a successful outcome can be given, but Kim ensures that all therapy methods that Kim uses are conducted professionally in accordance with required protocols and recognised guidelines. What Kim does guarantee you, is her 100% commitment which should be reciprocal as your same level of commitment is needed for the most effective therapy. The more open and forthcoming you are the more effective the therapy will be. The therapy plan is created from what you tell her in order to provide you with the best opportunity for positive change. It may be that as therapy progresses so too may the therapy method change to whatever is deemed necessary and most appropriate.
REFERRALS:
Clients will be discharged and referred to another therapist in the event of any of the following situations:
·      The therapy method employed is not appropriate and a suitable alternative is not available.
·      Any undisclosed mental or physiological condition is discovered or suspected.
·      Continued therapy would not provide you any further benefit.
·      A negative therapeutic transference develops.
·      Regular appointments are missed to the detriment of therapy.
·      Inappropriate behaviour is exhibited or developed.
By undertaking a course of therapy with Kim, you accept that she cannot guarantee the therapeutic outcome and that her fees are in consideration of her time and expertise regardless of the therapeutic outcome. Kim Barden Therapies reserves the right either to decline to accept or treat any client or individual. However, each client is considered on an individual basis and acceptance into, and continuation of therapy is entirely at the discretion of Kim Barden Therapies. Any individual who is under the influence of substances, including alcohol or drugs, will not be seen or treated.
PROGRAMMES/NO of SESSION(S):
To get the best out of the therapy it is important to book at least two sessions. All programmes must be used within 6 months.
FEES & PAYMENT:
The fee for the session is £90.00. To get the best out of the therapy it is advisable to book at least two sessions. Payment must be paid prior to the session. This not only guarantees you a time and date but your commitment to attend therapy. All programs must be used within a 6 month period.
CLIENT CANCELLATIONS/RESCHEDULE:
If for some reason you cannot attend the session and would like to cancel/reschedule, please contact Kim (WhatsApp)(Call) 07771 631 614 or email info@kimbarden.co.uk within 48 hours. However, Kim understands that life can throw curveballs and you may have to reschedule within a few hours. Kim hopes that clients appreciate that it is rarely possible to fill these appointments at such short notice, which is why we are obliged to charge for my time.
THERAPIST CANCELLATION/RESCHEDULE:
In the event of an emergency or unexpected illness, Kim will reschedule an appointment, however, she will only do so in the most exceptional circumstances and will give as much notice as possible.
GUARANTEE/REFUND POLICY:
BWRT® is a fast, effective therapy, however, there are no guarantees as to how well it works with each individual. BWRT® is goal orientated and result-driven. It is impossible to guarantee human behaviour or compliance, so no refund for services is given. As a MIBWRT® (Adv) Practitioner please consider Kim as a guide or facilitator to help you achieve your goal. It is important that you also assume equal responsibility by making a commitment and allowing yourself to be guided in your BWRT® session. That said, Kim sincerely wants you to succeed. You also confirm that you understand that you have other choices from which to seek assistance regarding your specific concerns, and you have chosen BWRT® at this time. Thank you!
RECORDING SESSIONS:
Recordings are STRICTLY forbidden.
MOBILE PHONES:
All mobile phones MUST be left outside of the therapy room. Please leave them in the hallway upon arrival.
CONFIDENTIALITY:
Kim will not disclose your personal information to any third party unless required to do so by law. The information you provide during your treatment will be held in strict confidentiality unless you instruct me in writing to share it with your GP or other healthcare professional. Kim is also bound by safeguarding rules. Kim adheres to the APHP Ethical Code of Conduct and The Terence Watts Institute and will maintain your personal data with the strictest confidentiality. Please visit www.aphp.co.uk or www.bwrt.org for further information.
PROTECTING YOUR INFORMATION:
This policy, together with our terms and conditions of business and any other documents referred to, sets out the basis upon which any personal data we collect from you or that you provide to me, will be processed by me. This privacy notice applies to the contents of the website
Confidentiality is paramount and will be maintained in all but the most exceptional circumstances. Situations, where information may have to be disclosed, are as follows:
·      If there is a serious risk of harm to yourself or to others, then your GP or the Police may be informed – it may not be possible to talk to you first
·      The courts can order disclosure of information in extreme circumstances. I would always seek advice from my insurers and legal team first before disclosing information
· Kim has mentoring but will not disclose any identifying information.
· Kim keeps notes, securely locked away. You are welcome to ask for a copy
·      Kim is also registered with the Information Commissioner's Office (ICO) as a Data Protection Officer. Case notes and correspondence are stored securely and treated confidentially according to the Data Protection Act. You can verify the ICO registration by going to the website at www.ico.org.uk.
INSURANCE:
Insurance is provided by: Oxygen Talking Therapy Insurance: https://www.marshcommercial.co.uk/for-business/oxygen
MOBILE PHONES:
Please turn off all mobile phones before arrival.
RECORDING OF SESSIONS:
Recordings are STRICTLY forbidden, either face-to-face or online.
Signature:*
Date:*
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How did you hear of Kim Barden Therapies?*

BrainWorking Recursive Therapy® (BWRT®)

Informed Consent to Treatment
BrainWorking Recursive Therapy® is a neuroscience-based process that has been shown to be useful to help reduce or alleviate the symptoms, and causes of symptoms, associated with anxiety, phobias, PTSD, depression, low confidence, and low self-esteem, and many other psychological issues. It works in a unique way to ‘defuse’ the psychological triggers of the symptom pattern before they reach the part of the brain that activates the emotional responses. In this way, the symptom is either alleviated or greatly reduced in severity. BWRT® mimics the way the brain and psyche acquire the difficulty in the first place and is therefore a totally natural process. The work does not require you to divulge any intimate details of your personal life or of any event that you wish to keep private that might have been the cause of your symptom. While there is not a therapy in the world that works for everybody every time, BWRT® is considered by many to be among the most reliable of psychological methodologies.
BrainWorking Recursive Therapy® was discovered in 2011 by Terence Watts, MCGI, a UK therapist, author and trainer in full-time private practice since 1989. After development and many practical trials with volunteers, BWRT® was taught for the first time in October 2013. One of the first students of the new technique was South African Clinical Psychologist Rafiq Lockhart whose extensive experience in the world of psychology led to him being quickly appointed as Terence’s research partner and ‘Mr BWRT South Africa.’ Terence and Rafiq continued to refine the process into the elegant system that it is today.
All trainers of this relatively new model of psychopathology are selected by The Terence Watts BWRT Institute and all adhere to the same training programme to ensure, as far as possible, consistency in technical expertise across the globe.
Kim was trained by: Terence Watts (MCGI)
By signing below, you indicate that you understand and accept the following (presented in no particular order):
1. BWRT® is designed to help neutralise triggers for the symptom(s) you experience. There are three levels of BWRT® and your practitioner will ask you some questions that will help them decide which is the most appropriate level for you.
2. There are a few conditions and situations in which BWRT® is not a suitable therapy and when this is the case, the practitioner will advise you accordingly.
3. The number of sessions you will need vary according to several circumstances and the practitioner will advise you where possible. Many situations respond well to between one and four sessions, though some more serious issues may need more.
4. You will not have to tell the practitioner any personal details you would rather keep private (save for clause 6, below) but there are some situations when secrets might inhibit therapy. The practitioner will advise you if this is the case.
5. If your presenting problem could be caused by a medical or physiological condition, you will need to have had a medical consultation before working with BWRT®.
6. If you have experienced any previous psychological illnesses or conditions, whether or not they received or required medical intervention, you will ensure the practitioner is made fully aware of the details.
7. Straightforward issues such as smoking cessation, phobias, fears and specific anxieties will not normally need any medical consultation before BWRT®.
8. There is no need for prolonged investigation into your early (childhood) years but if you feel they might have a bearing on your symptom, you can tell the practitioner and they will take that into account.
9. If your symptom was triggered by a past situation or trauma, you will be required to recall it for just a few seconds so that the degree of discomfort can be assessed via the Perceived Arousal Level (PAL). This also allows assessment of the degree of improvement after the process has been applied.
10. The practitioner may sometimes use their voice in a way that sounds unusual or strange to you. This need not concern you and is just part of the BWRT® Process.
11. There are several different ways that BWRT® can be conducted and the practitioner will be able to make the best choice for you and your presenting issue.
12. If the symptom or difficulty for which you are seeking help is part of, or likely to be part of, any legal proceedings, please take legal advice before embarking on treatment, since BWRT® changes your perception and responses to past events.
By signing below, you confirm that you have read and understood the above information and that you subsequently consent to BWRT® for your conditions.
Signature
Date
MM
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Name of Doctor*
Name of Surgery*
Address or Location*
GP Email*
GP Phone Number (if you have it)*
Dear
I am a patient of yours and my therapist wishes to contact you to check for any contraindications before commencing therapy.
I have signed this consent form authorising Kim Barden of Kim Barden Therapies to request this information from you.
Signature

Intake form

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LIABILITY DISCLAIMER

BrainWorking Recursive Therapy® (BWRT®)