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Registration for Empaths

Register for our "Nature Therapy for Animal/Earth Empaths" program covered by Alberta Health Care here

"Nature-based Grief Work for Animal/Earth Empaths" Registration Form

Thank you for your interest in this program

What is an "Animal/Earth Empath"?

An empath is someone who, in addition to having "Sensory Processing Sensitivity" (highly sensitive to stimuli such as light, sounds etc.), is also very attuned to what others are feeling ("affective empathy") to the point of experiencing the emotions of others within themselves. This program is particularly focused on helping those who struggle with grief, despair or overwhelm as a result of being especially sensitive to the suffering of animals and devastation of the environment (eco-anxiety/eco-grief). 

PLEASE READ the following prior to completing the intake form below: 

  • This is a Nature-based program to help highly sensitive women who struggle with grief or despair in response to the suffering of animals and our planet, create hope in their lives by embracing their grief and finding creative and personally meaningful ways to make a difference related to what most breaks their heart.  Minimum age for participation is 18 years old.

Please Note:  

  • This is an Experiential Therapy Program (versus talk therapy)
  • It can be helpful in conjunction with, but does not replace, talk therapy.
  • It is best suited for those who have already done some core work (with or without a therapist) related to family of origin and trauma-related issues, and are ready and motivated to take action to move forward in their lives. 
  • Medication/prescription management services are not provided
  • All participants must be followed by a family doctor/GP and, if indicated, a psychiatrist or other mental health professional. 
  • The sessions are primarily outdoors and involve time in Nature and with Horses, Donkeys, and other animals. The reflective/creative arts/integration components of the session will be in a heated/sheltered area or indoors if cold or raining.
  • Sessions run rain, snow or shine except for severe weather that affects road conditions or safety outdoors.

**IMPORTANT**
THIS PROGRAM IS NOT APPROPRIATE FOR INDIVIDUALS WITH ANY OF THE FOLLOWING:

•  Substance abuse/dependency (active or within last 3 years)
•  Hospital admission for psychiatric disorder within past 12 months
•  Mental Health issues that significantly impair daily functioning (e.g. not able to work)
•  Severe Anxiety, Depression or other Mental Illness
•  Suicidal thoughts or Psychosis
•  Borderline Personality Disorder

As I am not able to provide the level of support and care required

Moderate Anxiety or Depression must be under care of GP or Mental Health Professional        (and must be in at least partial remission)

Note: I am offering all therapy services as a physician under my medical license. The information gathered on this form is necessary to provide optimal services to you; meet the medical charting requirements of the Alberta College of Physicians & Surgeons; and to verify that the eligibility criteria are met for Alberta Health Care Insurance Plan (AHCIP) coverage. All information provided is confidential as per the Health Information Act (HIA) of Alberta. Thank you.

**Cancellation Policy
3 business days notice is required for cancelling a therapy session.

*N.B.: I can not bill Alberta Health Care if we do not have an in-person session (sessions can not occur via phone, Skype, etc.)

Excluding emergencies/extenuating circumstances, cancellations made with < 3 business days notice will be subject to the following fees. Fees, which cover only a portion of the Alberta Health Care billing rate, must be paid in full before your next session. 

No-Shows for scheduled sessions may result in discontinuation of further sessions. (No-Shows for initial intake session will not be rescheduled)

**Cancellation Fees**
Individual sessions: $160
Group Sessions/Workshops: $20/hr
1.5 hr    $30
3 hr       $60
4 hr       $80
6 hr     $120
8 hr     $160
 

 

NATURE THERAPY REGISTRATION FORM

Name *
Name
I agree to the following: *
(both boxes must be checked)
Introductory Intake Session Availability
Please check all time slots that you could be available. Weekend sessions are in great demand, so please indicate if a weekday is possible. Sessions last ~ 2.5 hrs and ongoing sessions are typically scheduled for the same slot each week with reassessment every 4 weeks
** Please bring your AHCIP Card to your intake session** (Enter 9 digit number without spaces)
Birthday *
Birthday
Address *
Address
Phone (Home) *
Phone (Home)
Phone (Cell) *
Phone (Cell)
Include name and location
Are you under the care of a Mental Health Professional? *
If yes, please provide details below
Provide name, credentials (Psychiatrist/Psychologist/Other) and location. Also include how long you have been under their care and frequency of appointments
Provide name, credentials (e.g. Neurologist, Chiropractor, etc.) and location
Please list any medications including dose and frequency
Please list and indicate if you have ever experienced an anaphylactic reaction. (If so please bring Epi-pen)
Please list any significant health issues (e.g. asthma, heart condition, diabetes. etc.)
1 (significant impairment/disability) → 10 (optimal)
Mental Health *
Have you ever been DIAGNOSED with (check all that apply):
Please list (e.g. depression, anxiety, insomnia, etc.)
1 (significant impairment/disability) → 10 (optimal)
1 (none/minimal) → 5 (moderate) → 10 (overwhelming)
1 (significant impairment/disability) → 10 (optimal)
e.g. Mindfulness, Meditation, Experiential Therapy, Time in Nature, etc.
Briefly describe your experience with horses, including any significant events.
Comfort Level with Horses
If from a doctor or other healthcare provider please include name
Emergency Contact Information
Full Name & Relationship to Registrant
Emergency Contact (Home Phone) *
Emergency Contact (Home Phone)
Emergency Contact (Cell Phone)
Emergency Contact (Cell Phone)

Thank you!