Complimentary & Alternative Health Care Client Bill of Rights

Practitioner Name: Perrine Dailey

Business Name: InnerGo Studio

Business Address: 812 James Avenue, St. Paul MN 55102

Telephone number: (Text) 651-315-1798 Home: (Messages) 651-222-2372

Email: innergostudio@gmail.com

As of July 1, 2001, Minnesota’s Freedom of Access to Complementary Care Law (Statute Chapter 146A) requires that you receive and acknowledge that you have received by your signature on this sheet, the following information prior to your treatment.

Perrine Dailey, hereafter, “the Practitioner” has the received following education, training & credentials:

• Usui/Tibetan Reiki Master - Rev. Susan H. Aguirre 3/2006
• Ordained Interfaith Minister - Universal Life Church 4/2009
• Extreme Kinesiology 3 Day Intensive - Dr. William Gustafson, 2005
• Basics of MetAlign Therapy 2 Day Workshop - Lucille Crow, 2006
• BA - Bachelors of Arts Degree: Sociology, Magna Cum Laude, Augsburg College, 1995

"THE STATE OF MINNESOTA HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PURPOSES ONLY. Under Minnesota law, an unlicensed complementary and alternative health care practitioner may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis from a licensed physician, chiropractor, or acupuncture practitioner, or services from a physician, chiropractor, nurse, osteopath, physical therapist, dietitian, nutritionist, acupuncture practitioner, athletic trainer, or any other type of health care provider, the client may seek such services at any time."

• Complaints: If the Client has a complaint or concern about the care or services they have received, the Client may contact the Office of Unlicensed Complementary and Alternative Health Care Practice located in Minnesota Department of Health:

• Mailing address: P.O. Box 64882, St. Paul, MN 55164-0882 Phone: 651-201-3728 Fax: 651-201-3839 Website: www.health.state.mn.us E-mail: richard.hnasko@state.mn.us

• Fees and Payment:

All sessions are billed at $30 - 60 per hour, depending on the service, with taxes included, and usually last about one to two hours depending on the individual’s needs. Payment is requested by check made out to InnerGo Studio, or cash at the end of a session. PayPal will be available on the website. This Practitioner is not on contract with any HMO’s, PPO’s, or any other Insurance Company to provide discounted services. Payment in full for services is expected at the time of service, unless otherwise arranged prior to the appointment . Partial payment and barters are also considered if requested in advance by the client. Fees do not include travel time if we meet outside of my home office. 

I respectfully request 24 hours notice for all cancellations via email or text. I am quite flexible about rescheduling and believe that healing happens when the timing is right for all. If I am unable to do my best work for you on our appointed day, I ask that you be flexible too if I request to reschedule.

• Change of Price: Clients have the right to reasonable notice of changes to the prices, services, or policies.

• Theory of Treatment: The state requires a “Plain language” summary of the “theoretical approach used to provide service to clients”. The Practitioner’s Theory of Treatment is: to utilize a combination of skills and approaches that include mentoring, ministering, listening, energy work and other suggestions as appropriate for the client to resolve and recover from issues they are facing and wish to change.

• Right to Current Information: Clients have the right to complete and current information concerning the practitioner's assessment and recommended service that is to be provided, including the expected duration of the service to be provided. 

• Right to Confidentiality: Client records are confidential and will not be released, unless authorized by the client in writing or as otherwise provided for by law. 

• Right to Self Access: Clients have the right to access to their own records maintained by the Practitioner’s office, in accordance with state statute sections 144.291 to 144.298; 

• Personal Interaction: Clients have the right to expect courteous treatment, free from verbal, physical, or sexual abuse. 

• Other Treatment Available: Other services are available to the Client in this same community. These can be located by asking the Practitioner or found online. 

• Right of Agency: The Client has the right to choose freely among available practitioners and to change practitioners after services have begun.

• Records Transfer: The Client have the right to coordinated transfer of your records when there will be a change in the provider of services

• Right of Refusal: The Client may refuse services or treatment, unless otherwise provided by law.

• Right of Nonretribution: The Client has the right to assert the any and all of above-mentioned rights without retaliation from the Practitioner.

I _______________________________acknowledge by my signature that I have received and understand the Complementary and Alternative Health Care Client Bill of Rights.  

Signature________________________________________________Date_________________