Parent/Guardian Client Agreement

Parent Responsibility for Child’s Well-being

and Agreement


Parental responsibility for well-being of your child

If your child has a specific medical condition or specific symptoms, somatic bodywork therapies may be contraindicated, including: craniosacral therapy, myofascial unwinding, orofacial therapy or developmental movement therapy. Because these somatic bodywork therapies, listed above, should not be performed under certain medical conditions, you affirm that you have named and described all your child’s known medical conditions. You agree to keep the practitioner updated as to any changes in your child’s medical profile and understand that there shall be no liability on the practitioner’s part should you forget to do so.  A referral from your primary care provider may be required prior to service being provided.

You understand that the somatic therapy that your child receives is provided for the basic purposes of balancing fascia & muscle tone & coordination, and restoration of the craniosacral & fluid rhythms. You understand that developmental movement therapy/reflex integration is provided for the activation of essential neural connections.  If you notice that your child is experiencing any pain or discomfort during a session, you will immediately inform the practitioner so that therapy may be adjusted to your child’s comfort.

You further understand that somatic bodywork such as myofascial massage/craniosacral therapy and developmental movement therapy/reflex integration should not be construed as a substitute for medical examination, diagnosis, or treatment and that you should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailments of which you are aware  in your child. You understand that somatic bodywork therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Payment Policy

Payment is due on the day of service. The practitioner can generate a statement for your insurance carrier or flex plan to facilitate your reimbursement request. Please check your benefit coverage first. Your service may be eligible for flex plan coverage, if your employer offers this benefit.

Client statement: You understand that payment is due on the day of service. Further, you agree to pay a processing fee of $10 for each payment that are not made on the day of service and additional bank fees for any check or debit that does not clear. You understand that the practitioner may discontinue sessions if payments are not current.

Cancellation Policy

Client statement:  You agree to comply with the cancellation policy, which requires 24 hours notice to Catherine Burns by phone, voicemail or text, at 612/227-3071 for any rescheduled or cancelled appointment. If you do not provide 24 hours notice, you will be responsible to pay the posted fee.