Constellation Questionnaire - Living Voice Medicine

First Name *

Last Name *

Email Address *

Phone Number *

Please indicate which format you are interested in: *Private 1:1 ConstellationGroup Supported Constellation

What is your inquiry? *

Do you have prior experience with constellation work? If so please describe.

If you are inquiring about a medical or mental health condition have you also had this assessed by a physician or psychotherapist? Please list any relevant diagnoses and medications.

Please tell me a bit about yourself and your background.

Anything else you would like me to know?

Mental Health Policy *Maris is not trained in mental health assessment or trauma support, and does not hold that particular kind of therapeutic space. This work is not recommended for people with unstable mental health conditions, those who are in crisis, or those who are experiencing substantial active trauma. Kindness to those who are, but other forms of healing work with practitioners who work directly with those conditions is recommended instead. If you are not in crisis, are in stable mental health, and not experiencing substantial active trauma please verify by checking this box.

Appointment and Financial Policy *Please check this box indicating you have read and agree to this Appointment and Financial Policy: 48 hour notice is required for cancellations and rescheduling. No refunds will be issued for no-shows or late cancellations. Appointment duration will not be extended for late starts unless the lateness is on Maris's end. Please contact Maris by e-mail if you will be late or are having technical difficulties. The session will be considered a no-show after five minutes without contact. Payments for sessions are submitted when scheduling or are otherwise due 48 hours in advance. Appointment rates are for the constellation which can take variable amounts of time, and not the full time reserved unless it is needed. There are no refunds for not liking the outcome of a constellation. If Maris finds that it is not advisable to do a constellation, she will issue a refund for a portion of the rate at her discretion.

Type your name in the box below to sign the Informed Consent and Hold Harmless Agreement (text below) *

Informed Consent and Hold Harmless Agreement

I, the electronic signer above, hereby authorize Maris Bergrune (legal name Melissa Rosenberger, hereafter referred to as Maris) to perform the following procedures and services as scheduled:

Constellation Facilitation: The facilitation of a family system, organizational, or nature constellations.

By scheduling a constellation with Maris I affirm that I have read the following statements and understand and consent to the conditions presented:

I understand that Maris is not a therapist or medical provider, and that this work is not therapy or medical treatment or a substitute for therapy or medical treatment. I understand that this work does not intend to diagnose, treat, or cure disease or mental illness. I understand that this work is not for people experiencing unstable mental health conditions, those who are in crisis, or those with substantive active trauma.

I understand that this work is transformational and that I am responsible for acquiring the mental health support, aftercare, or integration work needed to process this work, as recommended by Maris or according to my own self-assessment and judgment.

I will not hold Maris or The Golden Lyre LCC legally responsible for any physical, emotional, mental, circumstantial, or energetic effects that may occur in connection with my participation in sessions. I will be fully responsible for my well-being during my session, which includes disclosing any concerns and/or questions I may have before, during, or following my session.

I understand that Maris does not guarantee any specific result from session work and that she is unable to predict or control what my outcome may be. I am willing to assume the risk of this uncertainty. I understand that there are no refunds for not liking the result of a session. Payment is for the constellation which may or may not take up the entire appointment duration. There are no refunds for shorter constellations.

I understand that no guarantees can be given about the improvement or resolution of presenting issues and that the effects of constellation work are unpredictable.

With this knowledge, I voluntarily consent to the above procedures and services, realizing that no guarantees have been given to me by Maris regarding the cure or improvement of my conditions. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Maris and The Golden Lyre LCC and all its agents from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with the above mentioned procedures and services.

In signing I affirm that what I have shared in the Constellation Questionnaire is an accurate reflection of my intention and condition and that I have not withheld pertinent information.

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