BOOK A REFRESH | Miss Marianna

Book Your First Time Refresh Session in 3 Easy Steps!

Step 1 Fill out your Authorization & Consent Form

Step 2 Click the "Book Now" First Time Refresh Session Buttton

Step 3 Schedule Your Refresh Session & Complete Checkout

Please read and fill out the following guidelines, authorization and consent forms.

MARIWORKS PRODUCTIONS CONSULTING SERVICES

GUIDELINES

MARIWORKS PRODUCTIONS consulting services are provided through the scope of mental health first aid conducted in safe space environments as agreed upon by staff and clients in advance (face-to-face, by telephone, online platform such as Zoom or Facetime).

MARIWORKS PRODUCTIONS consulting services are utilized as a stepping stone for clients to self-advocate, seek out professional services and resources for rehabilitation, therapy or counseling and long-term care as needed. This first time Refresh Session will determine if consulting services will continue or if professional medical advice is needed.

Any suspicion of the influence of drugs or alcohol is a reason to terminate services.

Refresh Session consultation services times, payment methods and non-refundable service fees are determined and due prior to services rendered.

Clients may cancel scheduled Refresh Session consultation services 48 hours in advance with emailed documentation, including date and reason for withdrawal. Otherwise, sessions can not be rescheduled and are non-refundable.

A parent or legal guardian must sign if client is below 18 years of age.

CONFIDENTIALITY & RELEASE OF LIABILITY

I understand MARIWORKS PRODUCTIONS consulting services are confidential. I also understand that MCS staff operates under policies of mandated reporting to release confidential information under the following circumstances: knowledge of belief that I am in danger of hurting myself or someone else (PC Section 11166); reasonable suspicion that a child, dependent adult and/or elder has been abused or neglected (Welfare & Institutions Code 11165); or if I have made a threat to harm an identifiable victim, both the victim and law enforcement will be notified of the threat (Welfare & Institutions Code Section 5328).

I hold MARIWORKS PRODUCTIONS consulting services free from any liability that may arise during consultation, coaching sessions, activities and referral services received. I authorize release and exchange of my personal health information and/or records for the purpose of developing a strategic plan for comprehensive services for my overall heath, safety and well being. For safety, protection and quality assurance, Refresh Session Mental Health Consultations are documented, recorded and available for review. This certifies that I have read and understood the MARIWORKS CONSULTATION SERVICES guidelines and to abide by all of them.

DISCLAIMER

MARIWORKS PRODUCTIONS CONSULTATION SERVICES DOES NOT PROVIDE MEDICAL ADVICE.

The information, including but not limited to, consultation, text, graphics, images and other materials are for informational purposes only. No material is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you have read on this website.

First Name

Age

Last Name

Email Address

Address

Phone

Occupation

Are you a student?

Yes

Race/Nationality:

Gender Identity:

Emergency Contact Number:

Emergency Contact Name & Relationship:

How many children or dependents do you have?

Have you ever been hospitalized for mental or emotional challenges?

Have you ever been diagnosed with a physical, mental or emotional disability?

Have you had any previous counseling or therapy of any kind?

Yes

Are you curently taking any prescription medications?

Yes

If you answered yes, please elaborate:

If this Refresh was a gift, who gifted you?

Initials

I declare that the info I’ve provided is accurate; I agree to the terms and conditions within the guidelines, consent, authorization and release of liability forms.