Mind & Health Coaching Group

California Senate Bill SB-577 - Required disclosure statement for practitioners

Patient Disclosure

Name/ Date/Date of Birth

Address / phone / email

Name of physician / psychotherapist:      Nicole Boulanger

Welcome to my practice. As you know, I am a practitioner of Neuro-Linguistic-Programming (NLP). I am not a licensed physician or licensed mental health practitioner, nor are Neuro-Linguistic-Programming services licensed by the state. I am not licensed by the State of California as a healing arts practitioner.

Neuro-Linguistic-Programming is the practical science of detecting, evolving and using the conscious and unconscious thinking and behavioral patterns that we are constantly experiencing. Thus NLP is the communication field that enhances professional development and personal performance. NLP is about how people learn, communicate, change, and evolve themselves. It was originally developed by studying patterns of communication and thinking, used by highly successful people. NLP provides specific “how to” skills for creation change in one’s self and assisting others in becoming more resourceful and effective. MLP is a set of processes that can greatly improve your communication skills in any situation. NLP is truly empowering and helps you do whatever you do better!

As a practitioner of Neuro-Linguistic-Programming, I will provide you with the following kinds of services: I will help you set performance based goals, help you identify and articulate any barriers to achieving your goals, and help you identify patterns for success. I will help you to identify limiting beliefs and help you to update them. I will help you get clear on internal conflicts and assist you to integrate them. I have been practicing Neuro-Linguistic-Programming for many years. My training and education is described below:

I attended NLP Master Practitioner (1993), Palo Alto School of Hypnotherapy (1994), NLP Health certification (1996). Those training were taught by Tim Hallbom, Suzi Smith, Robert Dilts, Robert McDonald, Charles Faulkner, Tom Best, etc. I added Anthony Robbins’ Self development programs and translated in French “Date with Destiny” in San Diego (1997). I attended NLPCA Coaching Certification (2008) and Advanced Hypnotherapy certification (2009). From 2007 to 2009, I have acted as a Coach consultant in many of NLPCA trainings, and participated in the Stanford “Splash“ 2009 spring event, teaching NLP basic elements to young students.

In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sigh it. You will receive a copy. I will keep the original in my records for at least three years.

My method of treatment, Neuro-Linguistic-Programming, is alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code. I can offer you these services, subject to requirements and restrictions that are described fully on the back of this page.

If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor that you are receiving Neuro-Linguistic-Programming treatments.

Acknowledgement and consent to receive services:

I have read and understand the above disclosure about the Neuro-Linguistic-Programming treatments offered by Nicole Boulanger and Mind & Health Coaching Group. I have discussed with Nicole Boulanger the nature of the services to be provided. I understand that Nicole Boulanger is not a licensed physician and that Neuro-Linguistic- Programming services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Nicole Boulanger, and agree to be personally responsible for the fees of Nicole Boulanger in connection with the services provided to me.

I have received a printed copy of Nicole Boulanger’s qualification and a description of section 2&3 of SB-577, and understand them.

____________________________ ______________________________ ___________________________________________________________

Signature Print name Date


Section 2053.5 is added to the business and Professions Code, to read:

2053.5.(a) Notwithstanding any other provision of law, a person who complies with the requirements of Section 2053.6 shall not be in violation of Section 2051, 2052, or 2053 unless that person does any of the following:

I. Nicole Boulanger, do not”

(1) Conduct surgery or any other procedure on another person that punctures the skin or harmfully invades the body..

(2) Administer or prescribe x-ray radiation to another person.

(3) Prescribe or administer legend drugs or controlled substances to another person

(4) Recommend the discontinuance of legend drugs or controlled substances prescribed by an appropriately licensed practitioner.

(5) Willfully diagnoses and treat a physical or mental condition of any person under circumstances or conditions that cause or create risk of great bodily harm, serious physical or mental illness, or death.

(6) Set fractures.

(7) Treat lacerations or abrasions through electrotherapy.

(8) Hold out, state, indicate, advertise, or imply to a client or prospective client that I am a physician, a surgeon, or a physician and surgeon.

(b) A person who advertises any services that are not unlawful under section 2051, 2052, or 2053 pursuant to subdivision (a) shall disclose in the advertisement that he or she is not licensed by the state as a healing arts practitioner.


Section 2053.6 is added to the Business and Professions Code, to read:

2053.6. (a) A person who provides services pursuant to section 2052.5 that are not unlawful under Section 2051, 2052, or 2053 shall, prior to providing those services, do the following:

(1) Disclose to the client in a written statement using plain language the following information:

(A) That he or she is not a licensed physician.

(B) That the treatment is alternative or complementary to healing arts services licensed by the state.

© ) That the services to be provided are not licensed by the state.

(D) The nature of the services to be provided.

(E) The theory of treatment upon which the services are based.

(F) His or Her educational training, experience, and other qualifications regarding the services to be provided.

(2) Obtain a written acknowledgement from the client stating that he or she has been provided with the information described in paragraph (1) The client shall be provided with a copy of the written acknowledgement, which shall be maintained by the person providing the services for three years.

(b) The information required by subdivision (a) shall be provided in a language that the client understands.

©) Nothing in this section or in section 2053.5 shall be construed to do the following:

(1) Affect the scope of practice of licensed physicians and surgeons.

(2) Linit the right of any person to seek relief for negligence or any other civil remedy against a person providing services subject to the requirements of this section.

I have read and understand the disclosures in Sections 2 and 3, and have received a copy:


________________________ _________________________________ __________________________________________________________

Signature Printed Name Date

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