Informed Consent Informed Consent for Brainspotting TreatmentsClient Name(Required)Date of Birth DD slash MM slash YYYY Email(Required) Phone(Required)Purpose You are beginning sessions with Dr Shiva Golshani, M.A., Ph.D., a consultant trained in Brainspotting, a therapeutic method developed by Dr. David Grand. The purpose of this form is to help you understand the nature of Brainspotting and to confirm your consent to participate. Nature of Services Brainspotting is a mind–body technique that uses eye position to access and process unresolved trauma. * You are not required to verbally recount traumatic events unless you choose to. * Sessions focus on eye gaze, body sensations, and emotional processing to support natural self-healing.Consultant’s Training & Background * Dr. Golshani holds an M.A. in Cognitive & Developmental Psychology (UC Berkeley) and a Ph.D. in Educational Psychology (UCLA). * Her academic research and teaching have focused on motivation, adjustment, and resilience across psychology and education. * She has specialized Phase I, Phase II and Phase III training in Brainspotting under the guidance of Dr. David Grand and associates, applying evidence-based methods to support enhanced adjustment in personal, social, and academic settings. * Please note: Dr. Golshani is not practicing traditional psychotherapy, but rather provides Brainspotting interventions within her scope of expertise.Benefits, Risks & Alternatives * Potential Benefits: Relief of trauma-related symptoms, improved emotional regulation, enhanced performance, and creativity. * Potential Risks: Temporary increases in emotional or physical distress may occur while processing material. * Results cannot be guaranteed. Clients may pause or discontinue treatment at any time and may request information on alternatives. Confidentiality * Your privacy is protected by law and professional ethics. Exceptions include: * Suspected abuse/neglect of a child, elder, or dependent adult. * Imminent danger to self or others. * Court orders or other legal requirements. * Email and text communication may not be fully secure. These may be used for scheduling only unless you opt out. Tele health * Telehealth (video or phone) may be offered as an option. * Risks include technology failures and privacy concerns. Clients are responsible for ensuring a private, secure location during sessions. * Emergency procedures will be discussed prior to telehealth sessions. Fees, Payment & Cancellation * Fees are outlined in the Services & Fees section. * Payment is due at the time of service. * Sessions canceled with less than 48 hours’ notice will be billed at the full rate (except in emergencies). * Superbills may be provided upon request for out-of-network insurance reimbursement. Notice of Privacy Practices (HIPAA) * You have been offered a copy of the Notice of Privacy Practices. Clarifications may be requested at any time.Crisis & Emergencies * In case of immediate danger or a medical/psychological emergency, call 911 or go to the nearest emergency department. * Routine practice messages are not monitored 24/7.Client Rights * You may stop or pause a session at any time. * You have the right to ask questions, request clarification, or request referrals. * Participation is voluntary and may be discontinued at any point. Consent to Treatment(Required) By signing below, I acknowledge that I have read and understood this document, had the opportunity to ask questions, and voluntarily consent to Brainspotting consultation services with Dr. Shiva Golshani.Client SignatureDate MM slash DD slash YYYY Consultant SignatureDate MM slash DD slash YYYY
