Service Agreement

By signing below I hereby acknowledge, represent and agree that:

I am 18 and over years of age and/or parent/legal guardian of subject seeking services

I wish to obtain services at Marina’s Emotional Wellness Support from Marina Nabutovskiy BSN RN,CTMH-A, SSP Facilitator, ISPW Facilitator
I am currently under the care of a physician or other health-care practitioner

While receiving services at Marina’s Emotional Wellness Support from Marina Nabutovskiy, BSN RN,CTMH-A, SSP Facilitator, ISPW Facilitator, a list of available resources as options/ solutions will be offered, and I agree before undertaking any of these that I will consult my physician or other health care practitioner whose care I am currently under

I acknowledge by signing this form that I have not been hospitalized for psychiatric reasons or have been
prescribed/have taken psychoactive substances in the last year

I understand and acknowledge that Marina Nabutovskiy, BSN RN,CTMH-A, SSP Facilitator, ISPW Facilitator does not provide medical and/or psychiatric diagnosis, treatment or psychotherapy Payment policy: payment for services is due at the beginning of each scheduled session; not
reimbursable by medical insurance

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Cancellation policy: 24-hour notice required for full refund.