SRT Intake Form for Children

Welcome! For children ages 6 years old to 17, parents must help fill out and sign this intake. Eighteen year old teens require an adult intake.

The cost of SRT is $100.00 per hour unless prior arrangements have been made. Price can be adjusted depending on financial needs, which must be discussed in advance.

Sessions for teens are usually one hour and children 12 and under usually a half hour. You may pay with debit or credit on the payment page, or pay cash at time of your child’s session. Payment needs to be made in advance unless prior arrangements have been made.

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.

The parent(s) and child will decide if the child’s session will be the child alone or with the parent present. If the child reports severe abuse, homocide or suicide, Helen Bair is obligated to report this kind of information to to the parent(s). Otherwise, issues discussed during the session are kept in confidence.

For greatest anonymity, refrain from writing highly sensitive issues on this intake. Instead write, “to be discussed later”. Fill out intake well in advance of session then select ‘submit’ at the end and it will be emailed to

You are expected to discuss any current medications or recreational mind-altering substances your child is taking (legal or illegal), before treatment begins, as some medications/drugs may interfere with results.

  • 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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