Above Therapies
Services provided by Lenka Robitaille through Lenka R. LLC doing business as Above Therapies. Complete this form before your session.
I understand that these complementary wellness services support relaxation and well-being, do not replace medical care, psychotherapy, addiction treatment, or emergency care, and do not guarantee a particular result. Bio-Well is not a medical diagnostic test. I will consult my treating professional before changing prescribed treatment.
I consent only to the services selected below after they have been explained to me. I may decline, request an adjustment, or stop at any time. Touch requires my permission, which I may withdraw. I will report discomfort and health changes before each visit. New services or changed risks require fresh consent.
AcuDetox uses small acupuncture needles placed in the outer ear. Risks include pain, bleeding, bruising, dizziness, and a displaced or retained needle. Sterile, single-use needles are used. I will not remove needles myself or leave until Lenka confirms removal. Ear seeds may cause skin irritation, adhesive allergy, or pressure discomfort.
Sound and vibration may cause headache, ringing in the ears, discomfort, or sensory overload. Roxiva sessions are conducted with eyes closed; flickering light may trigger seizures, migraine, eye discomfort, nausea, dizziness, or distress. Separate Roxiva screening and consent are required.
Gentle breathing may cause tingling, dizziness, or lightheadedness. My session does not include rapid breathing or breath holds. I may return to natural breathing or stop. Meditation, somatic, energy, or hands-on practices may bring up uncomfortable emotions, memories, sensations, fatigue, or distress.
Group participants are asked to respect privacy, but their confidentiality cannot be guaranteed. Record sharing with a treatment program requires separate authorization or another lawful basis. In an emergency, Lenka may contact emergency services and share information needed for the response as permitted by law.
For electronic signing, entering my name and selecting “I agree and sign” expresses my intent to sign electronically. I may request a copy.
Check Yes or No for each item. Discuss Yes or uncertain answers privately with Lenka before the relevant service. Lenka may adapt, postpone, decline, or request medical clearance for a service.
1. Seizures, epilepsy, unexplained loss of consciousness, or flashing-light sensitivity
2. Migraines, eye conditions or surgery, or medication causing light sensitivity
3. Pregnancy, possible pregnancy, or recent childbirth
4. Heart or lung disease, uncontrolled blood pressure, or stroke history
5. Bleeding disorder, blood thinners, impaired immunity, or poor wound healing
6. Ear infection, broken ear skin, or allergy to metal, adhesive, or latex
7. Tinnitus, sound sensitivity, hearing or balance concerns
8. Recent surgery, significant injury, or medical restrictions
9. Panic, dissociation, trauma triggers, or mental health needs requiring adaptations
10. Intoxication, active withdrawal, or inability to give informed consent
Choose one. No permission is given if neither option is selected. Choosing No does not affect services.
YES I allow Lenka Robitaille through Above Therapies to take photographs with my agreement and post photos I approve on Above Therapies social media to promote its wellness services. I understand I may be recognizable and I will not receive payment.
NO I do not allow photographs for social media.
If I choose Yes, I may review and approve each photo before posting. Cropping and brightness adjustments are permitted; misleading edits are not. This permission excludes website use, paid ads, video, audio, testimonials, health information, and my name or account tag without separate permission.
Public photos may be copied or shared. I can withdraw permission in writing; Above Therapies will stop new uses and remove posts it controls as soon as reasonably practicable, but cannot remove third-party copies. Photos identifying protected clinical care or substance use treatment require separate authorization. Every identifiable person in a group photo must give appropriate permission.
Your answers and signatures are stored privately for Lenka’s review, not included in email notifications. Signature dates are recorded when you submit. This is not an appointment booking.
