Me University’s Spa Retreat Therapy Series:

Learning to Dance in the Rain

Last Name: ________________First Name: ________________Birth date: _____/_____/_____

Please circle one:

American Indian Asian/Pacific Islander Hispanic/Latino Black/African American
White/Caucasian Multi-Racial

Address (Street or Box #):

____________________________________________________________________________

City: ________________________________________ State: _______ Zip: ______________

Home phone: (______) ___________________ Cell phone: (____) ________________

Email: ______________________________________________________________________

Have you ever attended a Spa Retreat? No _____ Yes _____ # of time’s __________________

How did you hear about this retreat? ______________________________________________

Special Needs:
______________________________________________________________________

Payment Information:

Discount Code (if any): _______________ $100 off if paid in full at the time of registration (enter code PIF)
Total Fee: $_________

Type of Payment: Cash/Check/Charge/Financing

Charge to my (Please circle one): Visa/ Master Card

Card #__________________Exp. Date: ________CID # ______ (three digit # on back of card)

Or Check enclosed: Yes _____ Check #_______________ Amount: _______________

Signature: __________________________________________ Date: ______________

For More Information visit www.Marirossalexander.com or contact Marirossalexander@yahoo.com

 Me University’s Spa Retreat Therapy Series:

Learning to Dance in the Rain

LIMITS OF CONFIDENTIALITY
Contents of all therapy sessions are considered to be confidential. Both verbal information and written
records about a client cannot be shared with another party without the written consent of the client or the
client’s legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect

When a client discloses intentions or a plan to harm another person, the mental health professional is
required to warn the intended victim and report this information to legal authorities. In cases in which the
client discloses or implies a plan for suicide, the health care professional is required to notify legal
authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a
child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health
professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances

Mental Health care professionals are required to report admitted prenatal exposure to controlled
substances that are potentially harmful.

Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

Insurance Providers (when applicable)

Insurance companies and other third-party payers are given information that they request regarding
services to clients.

Information that may be requested includes type of services, dates/times of services, diagnosis, treatment
plan, and description of impairment, progress of therapy, case notes, and summaries.

I agree to the above limits of confidentiality and understand their meanings and ramifications.
____________________________________________ ____________________________
Client Signature (Client’s Parent/Guardian if under 18) Date

For More Information visit www.Marirossalexander.com or contact Marirossalexander@yahoo.com

 Me University’s Spa Retreat Therapy Series:

Learning to Dance in the Rain

I _______________________________, understand the activities in which I will participate, and
I specifically release and discharge Ross Behavioral Group/Me University/Embassy Suites Golf
and Spa Resort for any acts or omissions, negligence, recklessness committed by or on its behalf
by any of its officers, directors, agents, employees, volunteers and persons connected with its
organization from any and all liability, claims, injuries, damages and causes or action of any type
whatsoever arising out of or in any way connected with my participation in the activities of Ross
Behavioral Group/Me University, on July 29, 2011 to July 31, 2011.

Signature _______________________________________________
Date ___________________________

CANCELLATION POLICY
If you fail to attend this conference, we cannot use this slot for another client and you will be
billed for the entire cost of the missed conference.

A full fee is charged for your absence or no show cancellation with less than a two week notice
unless due to a documented illness or an emergency. A bill will be mailed directly to you or your
credit card on file will be automatically charged. In the event that you cancel with more than a
two week notice you will be charged a $150 non-refundable registration fee and the remaining
balance can be used for a future event

Thank you for your consideration regarding this important matter.

_________________________________________________________________
Client Signature (Client’s Parent/Guardian if under 18)
________________________________
Date

For More Information visit www.Marirossalexander.com or contact Marirossalexander@yahoo.com