Practitioner Commitment in Providing Services 

The Disclosures made here are accurate to the best of my knowledge and reflect my commitment to your therapy as my client. I will at all times endeavor to abide by the Code of Ethics I have adopted for myself. I will work with you in your energy therapy to reach the goals you have set for yourself and will not interfere with your own personal beliefs or energy efforts. If at any time I feel it necessary or advisable, I will discontinue our therapy sessions to prevent any harm to you, to myself as practitioner, or to my therapy practice. I have made these disclosures voluntarily and, while I make no representations that the information contained herein will remain accurate during the duration of our practitioner-client relationship, I will work within the terms of this disclosure as far as I am able. 

Client Acknowledgment and Consent to Receive Services 

I have read and understand the above Disclosure about the energy therapy treatment offered and have discussed with my practitioner the nature of the services to be provided. I consent to and affirm all the terms included in this Disclosure, and agree to read all material provided to me regarding my practitioner’s practice. I understand my practitioner is not a licensed physician and that energy therapy services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself with a medical doctor. I have consented to use the services offered, and agree to be personally responsible for all fees charged in connection with the services provided to me.