SRT Intake Form for Adults

Welcome to SRT – Subconscious Repairing Therapy! We are excited you have decided to experience this cutting edge therapy and expect you will have amazing results!!

The cost of SRT is $100.00 per hour. For adults, the first session is two hours, $200.00 total. Sessions for teens are one hour and children usually a half hour. Pay with debit, credit on the payment page of Web camera or phone sessions must be paid in advance. Discount prices available. Call 602-320-2233 for details.

Please give 24 hours advance notice to cancel or postpone. 

If you are late for your appointment, the time lost will be counted as part of your session time. If Helen Bair makes you late for your appointment, she will either make it up at a later time, or reduce the cost of your session accordingly.

All issues discussed are kept in confidence unless reporting homicide, suicide or child abuse. For greatest anonymity, refrain from writing highly sensitive issues on your intake. Save those for oral discussion.

You are expected to discuss any current medications or recreational mind-altering substances you are taking at the present time, legal or illegal, before treatment begins, as some medications may interfere with results. All drug concerns will be kept confidential.

SRT Terms and Conditions:

*I realize that my health and well being depend directly on how well I care for myself and acknowledge that my feelings, thoughts and desires ultimately determine the course of this therapy and every outcome in my life. * I realize substances I take into my body can affect the outcome of therapy. * I realize that blaming anything or anyone, including myself, is totally useless and that the only person who can ultimately heal me is myself, by my attitude, desires and making appropriate changes and choices. * I agree to be honest, open minded and willing to participate wholeheartedly in the work I am undertaking. * I agree to allow Helen Bair MAPC to treat me, or my dependent child, and hold her or any referring person or institution innocent of any perceived or real damages as a result of SRT. * I understand that this process is includes the client’s perception of God/Higher Power. * I hereby understand and acknowledge that SRT – Subconscious Repairing Therapy presents a potentially powerful mental and physical regulating tool. * I understand that personal results will vary and that there are no expressed or implied guarantees or warranties of results, only that Helen Bair MAPC agrees to try to the best of her ability to accomplish her part in meeting your objective of each session. * I am fully informed of the nature and usefulness of SRT therapy. * I understand that services rendered are not a substitute for professional medical, and/or psychological diagnosis and treatment. *I understand that whenever I have serious pain or persistent symptoms, I should seek professional diagnosis. *I understand that SRT is alternative therapy. * I agree that printing my name on this intake form is legally the same as if I were signing my signature in person. * I understand that there is some question of security on web camera or phone sessions. * I take full responsibility and hold Helen Bair, MAPC innocent if there is a breach of privacy due to technology issues.

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