Follow-Up Session Forms - Stacey Caster™

PSYCH-K®

Facilitator: Stacey Caster

Follow-Up Session Form

"*" indicates required fields

1Intake Form

2Consent Form

3Payment

How would you like your session?*

In-Person

Remote (Video or Phone)

Name*

First Last

City*

State*

Email (this will be used for appointment scheduling)*

Phone Number*

Do you authorize text messages for appointment information only*

Yes

Please provide a detailed list of all techniques, processes, or therapies you have explored before this session*

Do you have any physical challenges that would interfere with muscle testing? (e.g.: back/neck/arm pain or injuries)*

Yes

Knowing what you don’t want, isn’t the same as knowing what you do want. Moving away from pain is different than moving toward joy. During your session, you will have the opportunity to download and install your own tailor-made internal programs and beliefs to support the life you desire. Thoughtfully consider, and share, what unique beliefs, behaviors or actions you feel are important for your best session outcome.*

Goals… What are the top three things you would like to address?*

The following is optional, but helpful to ensure, together, we identify the best goal(s) for you.

Religious/Spiritual Affiliation/Beliefs:

Marital Status:

Number of Children:

Whether living or now passes, give one sentence that best describes the relationship with your parents.

Mother:

Father:

If there is anything additional you’d like to share or feel is important for me to know before our session, please share it here:

Overview of Services

PSYCH-K® is a process designed to help individuals change limiting subconscious beliefs to support positive change in areas such as personal growth, stress reduction, and goal achievement. As a certified PSYCH-K® Facilitator, I will guide you through simple, client-driven techniques that may involve the use of muscle testing and whole-brain integration.

PSYCH-K® is not a form of psychotherapy, counseling, or medical treatment. It does not diagnose, treat, or cure any physical or mental health condition. It is not a replacement for professional medical or psychological care.

Voluntary Participation and Scope of Practice

I understand that participation in a PSYCH-K® session is entirely voluntary.
I may decline to answer any question or stop the session at any time.
I understand that Stacey Caster is not acting as a licensed therapist, physician, or mental health provider.

Muscle Testing & Physical Contact

Some PSYCH-K® processes may involve gentle, non-invasive physical contact (such as muscle testing on the forearm).

I understand that I may decline physical contact at any time.
I agree to communicate clearly if I am uncomfortable with any part of the session.
Stacey Caster will make every effort to maintain my comfort and safety throughout the process.

Confidentiality

I understand that all personal information shared during the session will be kept strictly confidential.
My information will not be disclosed to anyone without my written permission, unless required by law.

Results and Responsibility

I understand that PSYCH-K® is a process, not a guarantee of results.
I acknowledge that any changes in my life following a session are my responsibility and may vary from person to person.
I release Stacey Caster from any liability for decisions or outcomes resulting from this work.

Acknowledgment & Consent

By signing below, I confirm that I have read, understood, and agree to the terms of this form. I consent to participate in PSYCH-K® facilitation sessions with Stacey Caster and understand the scope, risks, and benefits as described.

By typing my name below, I understand and agree that this is an equivalent form of electronic signature and as a manual signature.

Signature*

Date*

PSYCH-K®

Facilitator: Stacey Caster