NEW CLIENT INFORMED CONSENT FORM & CANCELLATION POLICY

CALIFORNIA SENATE BILL SB-577

California Senate Bill SB-577, effective January 1, 2003, enables complementary and alternative health practitioners to provide and advertise their services legally, according to certain rules of compliance specified in the legislation. Section 2053.6 of the California Business and Professions Code requires the following disclosures:

What does Senate Bill SB-577 mean for you, the client?

SB-577 gives you access to alternative and complementary health care practitioners. You must be given information about the nature of treatment and the practitioner’s qualifications. Feel free to ask a practitioner any question you might have about your treatment. Check to see if your practitioner has been certified by a professional membership society. In addition, tell your doctor about any alternative treatment you are pursuing. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet your health care needs. SB-577 helps to protect you. SB-577 requires unlicensed alternative health care practitioners to follow certain guidelines and restrictions.

Here are the things that unlicensed alternative practitioners are NOT allowed to do:

  • Perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.

  • Use X-ray radiation.

  • Prescribe prescription drugs, or recommending that you discontinue drugs that were 
prescribed by a licensed physician.

  • Set fractures.

  • Treat wounds with electrotherapy.

  • Put you at risk of great bodily harm, serious physical or mental illness, or death.

  • Imply in any way that they are licensed physicians.

Disclosure to the client in plain, written language that:

  • that the practitioner is not a licensed physician;

  • that the treatment is a complementary or alternative healing modality and not 
licensed by the state;

  • the nature of the service to be provided and the theory of treatment upon which the services are based; and

  • the practitioner‘s education and other training, experience, and other qualifications regarding the services to be provided.

I understand that Wendy Shubin, MSPAS, PA-C is a licensed Physician Assistant and NOT a licensed physician in California and does not possess a physician license from the state of California.  I understand that Wendy Shubin, MSPAS, PA-C is NOT practicing as a licensed medical provider (PA-C) in while providing Yoga Therapy, ELDOA™, SOMA Training, SOMA Therapy, CranioSacral Therapy, and Lifestyle Coaching services. I understand that Wendy Shubin, will NOT diagnose, prescribe, treat or cure any medical conditions while providing these services.

I also understand that Yoga Therapy, ELDOA™, SOMA Training, SOMA Therapy, and CranioSacral Therapy, and lifestyle coaching are all forms of complementary and alternative medicine not licensed by the State of California. Wendy Shubin can offer you these services, subject to requirements and restrictions that are described in this document. In practicing complementary and alternative medicine Wendy Shubin seeks to support rather than replace the care of your existing doctors and practitioners.

As a practitioner of Yoga Therapy, ELDOA™, SOMA Training, SOMA Therapy, CranioSacral Therapy, Lifestyle Coaching, I will provide you with the following kinds of services:

  • Yoga Therapy is a method of practicing and teaching yoga that supports the therapeutic qualities of yoga- preventing injury while simultaneously rehabilitating physical, energetic and emotional challenges throughout all stages of life and within all levels of a yoga practice.

  • ELDOA™ was developed by world renowned French Osteopath, Dr. Guy Voyer.  The ELDOAs are precise self-normalizing exercises that create healthy tension on the fascial line to decompress articulations (joints) in the body.  Most ELDOAs focus on the spine, strengthening muscles along the back body and stretching tight or constricted fascia to create a normalizing effect amongst tissues surrounding the central nervous system.

  • Soma Training was created as part of Dr. Guy Voyer’s osteopathic approach to medicine.  Through the knowledge he gained as a trained Physical Therapist, Medical Doctor and Doctor of Osteopathy, along with his clinical experience with patients, Dr. Voyer learned the best way to heal the body is by using the body itself.  Using the philosophies of osteopathy revealed the dynamic view of a complex body system that Dr. Voyer, DO blended into many classical principles of exercise that include segmental stretching, decompression and proprioceptive actions to not just to strengthen the body, but to normalize tissues in a meaningful way. Along with ELDOA™ and CranioSacral & Soma Therapy, Soma Training enables you to work with and relieve a host of conditions correcting imbalances with stretching and strengthening muscles, improving balance and coordination with proprioceptive exercises.  This paradigm helps individuals build functional strength, body awareness and power to healthfully execute work-outs and activities of daily living.

  • Soma Therapy is a clinician-based program designed to teach the fundamentals of normalizing fluid flow in all fascia/joints/dura mater.  Space and flow are the 2 most basic principles fundamental to health, resilience and performance.  Soma Therapy, at its core, teaches how to intelligently create space and flow in all systems. Soma Therapy includes a gentle manual manipulation of the joints and fascia to bring fluid from the extracellular space into our cells, fascia, and joints to decrease inflammation and promote normalization of joints for the body to heal.

  • CranioSacral therapy is a holistic healing practice that uses very light touch to balance the craniosacral system in the body. CranioSacral Therapy is a specialty training to work with the bones of the cranium, the fascial coverings (meninges), the fluids, and especially the central nervous system (the brain) to access the whole person, for both treatment of dysfunction and improvement of health. Sometimes called cranial osteopathy, it is an additional set of skills gained by licensed medical providers to better address the whole body. By normalizing the environment around the brain and spinal cord and enhancing the body’s ability to self-correct, CranioSacral Therapy is able to alleviate a wide variety of dysfunctions, from migraine headaches, back pain, chronic pain and sports injuries to stroke and neurological impairment. CranioSacral Therapy is not for everyone, like all forms of treatment. It can be used as stand-alone treatment or may need to be used in conjunction with other healing modalities including soma therapy, chiropractic, osteopathic, acupuncture and/or allopathic medical treatments. Correction of posture, body mechanics, ELDOA, strength training, myofascial stretching and proprioception & awareness exercises will be imperative to long-term health and healing.

  • Lifestyle Coaching includes us going over what you do day to day (sleep, work, exercise, relationships) and seeing where simple daily improvements can be made so you will be living your best choices for being in harmony with you are as an individual and not just following societal standards.

Educational Qualifications and Training to Practice Yoga Therapy, ELDOA™, SOMA Training, SOMA Therapy, CranioSacral Therapy, Lifestyle Coaching

Education:

  • Arcadia University: Masters of Science in Physician Assistant Studies, Glenside, PA, 1999 – 2001

  • Indiana University: Bachelors of Arts in Psychology with concentration in General Sciences, 1994 – 1998

Certified Yoga Therapist:

  • ​Certified Yoga Therapist, International Association of Yoga Therapists. Awarded 4/1/2017

  • liv-INg-yoga with jasmine lieb, 1000-hr Yoga Therapy Teacher Training 2013 – 2016

Yoga Teacher Trainings:

  • Bhakti Yoga Training, Shaktirasa School of Tantra, Yoga, Ayurveda, Katie Silcox, 50 hours, 2017

  • Laya Yoga Training, Shaktirasa School of Tantra, Yoga, Ayurveda, Katie Silcox, Nicaragua, 50 hours, 2016

  • Strong Yoga®4Fertility Teacher Training, Brenda Strong, YogaWorks, Santa Monica, CA 2009

  • Strong Yoga®4Fertility, Teacher Trainer, Teacher Training, Monterey, California, 2013

  • Ashtanga Yoga Teacher Training Primary Series, Jennifer McLaughlin, Sol Studios, Amber, PA, 2001

Yoga Continuing Education:  

  • Meditation Immersion with Steve Ross, 2016

  • Sun Salutation Immersion, Kathryn Budig, YogaWorks, Santa Monica, CA, 2014

  • Core Strength and Balance Immersion, Heath House, YogaWorks, Santa Monica CA, 2011

  • Ashtanga Immersion, David Williams, Los Angeles, CA, 2011

  • Adjustment Clinic, Sonia Cottle, Santa Monica, CA, 2009

  • Yogic Philosophy and the Mahabharata, Raghunath Cappo, India, 2008

  • Inversion Workshops, Raghunath Cappo, 2008, 2009

  • Teacher Training Immersion, Kia Miller, YogaWorks, Santa Monica, 2008

  • Ashtanga Workshop, Manju Jois, YogaWorks, Los Angeles, CA, 2006

  • Yoga for Scoliosis, Elise Miller, YogaWorks, Santa Monica, CA, 2005

  • Adjustment Training: Assistant Instructor, Twister’s Yoga Studio, Erdenheim, PA, 2004

  • Ashtanga Immersion, David Swenson, Lehigh Valley Yoga Center, Allentown, PA, 2004

ELDOA™ Certifications:

  • ELDOA™ 4, Guy Voyer, MD, DO, Long Beach, CA 2/2019

  • ELDOA™ 3, 4, & 5, Guy Voyer, DO, Santa Monica, CA, 6/2018

  • ELDOA™ 3, Bryce Turner, Seal Beach, CA, 7/2018

  • ELDOA™ 2, Bryce Turner, Seal Beach, California, 3/2018

  • ELDOA™ 1, Bryce Turner, Seal Beach, California, 2/2018

ELDOA™ Continuing Education:

  • ELDOA™ 1/2 Teacher Training Assistant, Bryce Turner, ELDOA USA, 6/2020

  • ELDOA™ 1/2 Teacher Training Assistant, Bryce Turner, ELDOA USA, 7/2019

  • ELDOA™ 1/2 Teacher Training Assistant, Bryce Turner, ELDOA USA, 12/2019

  • ELDOA™ 3 Teacher Training Assistant, Bryce Turner, ELDOA USA, 3/2019

  • ELDOA™ 2 Teacher Training Assistant, Bryce Turner, ELDOA USA, 3/2019

  • ELDOA™ 1 Teacher Training Assistant, Bryce Turner, ELDOA USA, 2/2019

Soma Training Certifications:

  • Myofascial Stretching, Brent Meier & Bryce Turner , 2020

  • Orthopedic Strapping, Brent Meier, 2019

  • Proprioception and Awareness, Guy Voyer, DO 1/2018

  • ELDOA™ 3, 4 & 5, ,Guy Voyer, DO, 6/2018

  • Analytical & Segmental Strengthening of the Lower Limbs, Brent Meier & Bryce Turner, 8/2018

  • Analytical & Segmental Strengthening of the Upper Limbs & Trunk, Brent Meier & Bryce, 5/2019

  • Analytical & Segmental Strengthening of the Abdominals, Guy Voyer, DO, 4/2018

  • Qualitative and Quantitative Periodization, Guy Voyer, DO, 2/2018

  • Global Postural Stretching, Guy Voyer, DO, 1/2019

  • Circulatory and Respiratory Techniques, Guy Voyer, DO, 11/2018

Soma Training Continuing Education:

  • Myofascial Stretching, Bryce Turner, 4/2021

  • Global Postural Stretching, Dan Hellman & Bryce Turner, 9/2020

  • Diastasis Recti Workshop, Laura Adams and Bryce Turner, 4/2018

Soma Therapy Certifications:

  • Cranial Diaphragm Theory & Technique, Guy Voyer, DO, 6/2021

  • Cervical Diaphragm, Technique, Jason Amstutz, DC, 6/2021

  • Pelvic Diaphragm Technique, Jason Amstutz, DC, 5/2021

  • Pelvic Diaphragm Theory, Guy Voyer, DO, 5/2021

  • Cervico-Thoracic Diaphragm Technique, Jason Amstutz, DC, 3/2021

  • Cervico-Thoracic Diaphragm Theory, Guy Voyer, DO, 2/2021

  • Thoracic Diaphragm Techniques, Jason Amstutz, DC, 12/2020

  • Thoracic Diaphragm Theory, Guy Voyer, DO, 11/2020

  • Transverse Tendinous Ligamentous Stretching for Trunk and Pelvis, Jason Amstutz, DC, 11/2020

  • Transverse Tendinous Ligamentous Stretching for Upper Limbs, Jason Amstutz, DC, 1/2020

  • Transverse Tendinous Ligamentous Stretching for Lower Limbs, Jason Amstutz, DC, 11/2019

  • Fascia Normalization of Trunk and Pelvis, Jason Amstutz, 2/2020

  • Fascia Normalization of the Upper Limbs, Jason Amstutz, DC, 3/2019

  • Fascia Normalization of the Lower Limbs, Jason Amstutz, DC, 1/2019

  • Osteo-Articular Pumping of the Trunk and Pelvis, Jason Amstutz, DC, 10/2018

  • Osteo-Articular Pumping of the Upper Limbs, Jason Amstutz, DC, 7/2018

  • Osteo-Articular Pumping of the Lower Limbs, Jason Amstutz, DC, 5/2018

Osteopathic Continuing Education:

  • Pre-Conference: Manual Medicine: Hands-On Healing in the Clinical Setting: Kirsten Mackey, DO, 2016

CranioSacral Therapy Certification:

  • CranioSacral Therapy, CST2, Upledger’s Institute International, 5/2020

  • CranioSacral Therapy, CST1, Upledger’s Institute International, 2/2020

If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor, and/or other practitioners you are seeing and find applicable, that you are receiving the Yoga Therapy, ELDOA™, SOMA Training, SOMA Therapy, and CranioSacral Therapy, Lifestyle Coaching.

Cancelation Policy

Please arrive on time for your appointments. If you are more than 15 minutes late you will be billed for your full reserved appointment time. Cancellations are required at least 48 hours prior to your appointment time to avoid a late cancellation charge. Client will be charged the full treatment fee for late or missed appointments at the next appointment time unless the time slot is filled by another client.

By completing the contact form below you acknowledge receipt of the information provided in this form and that you signed it. You will receive a copy upon request. I will keep the original in my records for at least three years.