Intake Form

Welcome!

Before filling out the intake form

Please read my Informed Consent Document, which outlines the nature of my practice and limitations of liability, as well as business policies. By submitting this intake form you agree to the contents of the Informed Consent Document— this form and the informed consent act as a contract between all clients and myself for our session work.

Session length:

  • 60 min (online, via zoom)

  • 60-75 min (in person) (please schedule 75 min; we might not need all of this time).

IF WE ARE MEETING ONLINE

Online Address

  • Zoom Address (for online appointments): https://us02web.zoom.us/j/9055267733

Getting Ready to Meet Online

  • Insure your camera and microphone are in working order.

  • Laptop or desktop is preferable to a mobile phone.

  • In Zoom Settings, please select “Speaker” view and pin my image; rather than a Gallery view where you are looking at yourself during the session. I can assist with this if you’re unsure how to do it.

  • Please be seated in a quiet place. I do not to do sessions with clients who are driving or multitasking.

  • Depending on the kind of session we do, and if we want to work with the body, it is sometimes helpful to have a place to lie down like a bed, sofa, or mat.

IF WE ARE MEETING IN PERSON

In Person Address

50 Seward St., San Francisco, CA.

What to Wear

No special clothing is required. Dress comfortably. It is preferable to wear pants rather than a dress.

Accessibility

I see clients in person at my home office. To access the treatment space requires walking down and back up a flight of stairs. If this is a challenge for you, please let me know in advance. I can make an accommodation to do the session on the entry level floor that doesn’t require stairs.

Parking

There is usually plenty of parking in the area; if not on my street, there are usually spots on the adjacent streets (Douglass or 19th St). It is a hilly area. If you have mobility challenges and can only find a spot downhill, please contact me and I can support you getting up to my place.

Public Transportation

The Castro MUNI station is the nearest transit. It is a 15 minute walk from Castro Station (it is an uphill climb). Uber or Lyft are recommended if you have mobility challenges. .

When You Arrive

Please don’t knock or ring if you arrive early; I am often finishing another appointment in person or online and may not be able to answer you. There are chairs in the garden area in front of the house you can sit on if you arrive early. At or after your appointment time, feel free to ring both doorbells (top & bottom).

PAYMENT

Fee:

  • $200

    Payment Methods

  • Zelle (preferred)— send Zelle transfer to polaritytherapyinstitute@gmail.com.

  • Venmo (@jansen-wellness); (<— click link) please use this exact user name; do not enter any other email address or other name.

  • Credit Card (<-- click link) includes an additional 4% processing fee.


  • Payment Policy: Payment is due prior to the appointment. If you haven’t paid before the appointment we will take care of that first, before beginning session work.

  • Cancellation Payment: In the event of cancellation with less than 48 hours notice, payment is due immediately. Past due payments will be sent to a Collections Agency.

CANCELLATION & RESCHEDULING

Notice Requirements: Cancellations or reschedules with more than 48 hours’ notice incur no charge. Cancellations or reschedules with less than 48 hours’ notice will be charged the full session fee, payable at the time of cancellation. No-shows also incur the full session fee.

Preferred Notice: Whenever possible, I appreciate more than 48 hours’ notice if you need to cancel or reschedule. If an in-person session is not feasible, an online session is always an option.

Late Payments: Outstanding balances must be settled promptly. Past-due payments may be referred to a collections agency.

Provider Cancellations: Occasionally, I may need to reschedule due to my teaching commitments. If this occurs, I will notify you in advance and make every effort to find a time close to your regular appointment.

ONGOING APPOINTMENT POLICY

Consistency in Scheduling: After up to three initial sessions, clients are asked to establish a regular appointment schedule—weekly, biweekly, or every four weeks. I do not currently offer sessions on an as-needed basis (i.e., random scheduling times) except during the initial trial period for up to three sessions. After this period, I only see clients who are able to commit to a regular schedule of sessions.

Rescheduling Needs: To maintain the integrity of your care, if you cancel an appointment, I ask that you reschedule within the same time period (e.g., for a biweekly schedule, within two weeks). This helps ensure continuity and honors the agreed-upon frequency of sessions.

Frequent Changes: If cancellations or reschedules become frequent, we may need to adjust your appointment frequency or discuss the possibility of releasing your regular time slot. Before making changes, we can explore scheduling alternatives to see what best supports your needs.

PLEASE FILL OUT THE FOLLOWING AT LEAST 48 HOURS PRIOR TO OUR SESSION:

 

If you are a minor, please have your parent/guardian click this link to provide consent for services.