Consent Form – Stascha Stahl

Informed Consent and Full Disclosure Document

The purpose of this document is to clearly delineate the scope of practice assumed by Stascha Stahl and to ensure that no misunderstanding occurs between herself and any clients as to the expected course or progression of treatment.

Please read the statement below and sign your agreement with it:

California Senate bill sb-577, which was signed by the governor in September 2002, has profound implications for the practice of alternate forms of health care in California. Sb-577 enables alternative and complimentary health care practitioners to provide and advertise their services legally. However, they must also comply with certain requirements specified within the bill.

Here are some things unlicensed alternative health care practitioners are NOT allowed to do:

perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
use X-ray radiation
prescribe prescription drugs, or recommend that you discontinue drugs that were prescribed by a licensed physician
set fractures
treat wounds with electrotherapy
put you at risk of great bodily harm, serious physical or mental illness, or death.
imply in any way that they are licensed physicians.

In addition, an unlicensed alternative practitioner MUST DO the following things:

provide you with a statement, written in plain language that includes the following information: (1) that they are not a licensed physician and that their services are not licensed by the state; (2) a brief and clear description of the kind of services they provide and the reasoning behind it; (3) a description of their education, training, and experience.
ask you to sign an acknowledgement that you received the above written statement, and provide you with a copy of it. They must also keep a copy of your signed acknowledgment for three years.

The state of California does not at this time license herbalists. Stascha Stahl is not a medical doctor and does not claim to diagnose, treat, or cure any medical conditions or pathologies nor prescribe medicine nor in any way represent herself as so doing. For any condition, you are advised to seek care from an appropriate medical practitioner. Whether you choose to engage a medical practitioner or not for your care is your right and Stascha Stahl assumes no responsibility for your decision in this matter.

Informed Consent and Full Disclosure Agreement

I have read and understood the statement above.
I, the undersigned, assume all responsibility for decisions I make regarding my health, recognizing that (a.) no claims are made for herbal medicine, nutritional or dietary recommendations to treat or cure any medical condition (b) all information given is for educational purposes only (c) there is no implied or stated guarantee of success or effectiveness of any specific treatment plan or guidelines (d) I am free to act upon or disregard the recommendations of Stascha Stahl as I so choose. I hereby release Stascha Stahl from all responsibility or liability for my actions and any consequences thereof in the present time and in the future with no constraints. I hereby affirm that I consent and agree to the above statements of my own free will and request to engage the services of Stascha Stahl in a professional relationship pursuant to the statements herein.

Signature

Date

Agreement to Pay for Services

I have read and understood the statement below.
I agree to pay for services and formulas at the time of appointment or prior to picking up tinctures, unless otherwise arranged. I understand Stascha Stahl’s scope of practice, services and fees.

Signature

Date

Message

Philosophy of Practice

I practice holistic, integrated healthcare. This approach assumes that the whole is greater than the sum of the parts and the patient has an innate ability to heal, which is my job to tap into. In a consultation we will address issues of diet and nutrition, exercise, rest, and play. I try to foster a sense of wholeness in my clients and to encourage their deep connection to the plant world. I encourage the client to create a healing team around themself and I expect my clients to actively engage in the healing process and to fully participate with me in seeking optimal health and wellbeing.

I want herbs to be accessible and have a sliding scale payment structure available by request.

Education and Clinical Experience

I have been practicing Western herbal medicine for eleven years. A listing of my teachers and description of my education is described below:

Juliet Blankespoor – Founder/director of Chestnut School of Herbal Medicine. I attended a 1000 hour herbal course in North Carolina where I learned about physiology, specific indications, and botany.
Chuck Garcia – Noted curandero and founder/director of the California School of Traditional Hispanic Herbalist. I have attended clinical skills and other classes with Chuck.
Jasmyn Clift. – Founder/director of WildSeed School of Herbal Studies in Salt Spring Island, BC. I attended a 128 hour case studies course, 20 hours of flower essence studies as well as many other classes.
Mimi Kamp – founder of essence of the desert – I have spent some time with Mimi learning about flower essences.
Student Clinic at San Francisco Botanical Medicine Clinic – Joshua Muscat oversaw my clinical intakes.
Student Clinic at the Wellness Center in Vancouver BC, Canada. I had a 6 month internship at an herbal wellness center in the downtown Eastside of Vancouver.
I have in the past and continue to keep a strong course of independent study going in whatever subject seems pertinent to the practice of Western herbal medicine.
I learn from the plants when I’m in the field and with clients.

What to expect in an initial consultation

The first visit lasts between 90-120 minutes. I will ask many questions about different body systems. We will discuss current health concerns, past medical history, family health, diet and exercise habits, emotional well-being and state of mind. I will review any medical diagnosis and work with you to to determine how best to approach your health concerns. From this case review I will evaluate the healing priorities and create a customized protocol of herbs and supplements.

Follow up consultations

Follow up visits are 45 minutes and are usually held every 4-6 weeks. In these sessions we will evaluate the progress, discuss any problems or concerns that have arisen and review the treatment protocols. Generally, I will dispense your herbs while you are in the office. If we are meeting over the phone, I will fill the formula for you to pick up. I require you to have at least one follow up appointment every 3 months, as it is important to track your progress.

Dispensary procedure

I may need up to a week after an appointment to evaluate all of the information and write you a program. This is emailed to you and then we will talk for 15 minutes by appointment over the phone to discuss any questions you need answering before commencing the program. Once you consent, I will pour the formula and you can pick it up from a cabinet behind my office or I can ship them to you. I ship herbs each Tuesday. Please consider this timing when you ask for refills to be shipped.

If I do not need a week to review information, I will dispense herbs at the time of the visit.
If you are requesting a refill or any herbs, I may take up to 7 days to fill the formula. Please allow for this when you time your request.

Costs

Initial appointments are $120. This includes our 90-120 minute interview, my time developing the protocols and answering your questions at our outtake.
Follow up appointments are $10-50 sliding scale.
Missed or canceled appointments without 24 hours notice incur a $25 fee.
Quick questions via phone, text, or email are subject to a $1/min fee.
Remedies and herbal formulas are priced individually. They are $6-8/oz. I will always let you know the cost of the medicine prior to pouring and pour only if you consent to the price. I usually recommend a main formula:
- For a simple condition you can expect between 8-12 oz/month which translates to $56-84 monthly.
- For complicated cancers or auto-immune conditions, the formula is generally between 12-18 oz/month and the cost will be $84-126 monthly
- At times I recommend sub-formulas or simples to take acutely. These are not included in that estimate.
Shipping is between $9.30-24.95. This will be added on to the price of the tinctures.

I am committed to keeping herbs accessible. I have a sliding scale and am willing to work out alternative payment agreements. Please feel free to discuss these with me!