Client intake & participation choices

Printable review worksheet — not an active intake form. Do not send completed sensitive information through the website or ordinary email. The secure intake process, final policies, practitioner scope, and service details must be approved before use. This page does not submit, store, or transmit answers and is not an electronic signature system.

1. Session details

Client name

Preferred contact (provide through the selected secure intake channel)

Session date, practitioner, location/format, agreed length and price

What would you like from this session? Share only what you are comfortable sharing.

2. Comfort and participation

Would you like to discuss sound sensitivity, seating or movement preferences, touch boundaries, accessibility needs, or another concern relevant to participating? A detailed trauma history is not required. Questions about medical suitability should be directed to an appropriate licensed professional.

□ I prefer a seated session. □ I prefer lying down. □ Please discuss options with me.

□ No touch. □ Discuss any proposed touch individually before proceeding.

Areas or activities to avoid, preferred adjustments, and a pause/stop signal:

3. Choose each proposed practice

Nothing is preselected. The practitioner explains each proposed method before the client chooses. “Discuss first” is not consent to begin. Only methods the practitioner is qualified and authorized to provide may be selected.

Proposed practice	Agree	Decline	Discuss first
Sound bowls / gong / percussion	□	□	□
Energy healing / chakra balancing	□	□	□
Spiritual coaching / guided meditation	□	□	□
Hypnosis — scope review required	□	□	□
Access Bars / proposed head touch	□	□	□
Tuning forks / placement explained	□	□	□
Emotion Code — training/authorization to confirm	□	□	□
Body Code — training/authorization to confirm	□	□	□
Belief Code — training/authorization to confirm	□	□	□
Heart-focused work — exact method to confirm	□	□	□
Muscle testing, magnets, or other tools — specify separately	□	□	□

Exact tools, touch, placement, spiritual language, alternatives, and limitations discussed:

No proxy work, work on an absent person, recording, or photography is authorized by this worksheet. Any remote/proxy arrangement requires its own explanation and agreement by the person participating.

4. Blended sessions: consent continues

I understand that agreeing to one practice does not mean agreeing to all practices. Before introducing a different method or materially changing the approach, the practitioner will explain it and ask again. I may decline, ask for an alternative, change a preference, pause, or end participation. I do not have to explain why.

The practitioner and I discussed the proposed blend, relevant limitations, and what may be uncomfortable. I have had a chance to ask questions. A signed general form does not replace conversation or ongoing agreement.

Agreed session plan, alternatives, and client boundaries:

5. Acknowledgments

□ I understand these are complementary wellness/spiritual practices, with no guaranteed outcome and no substitute for licensed care.

□ I understand spiritual or muscle-testing impressions are not medical diagnoses or verified evidence of past events.

□ I understand hypnosis impressions are not verified memories; I may remain aware and stop participation.

□ I received the final booking/refund terms and privacy notice, including the agreed policy if I end a session early.

□ I know the practitioner's identity and relevant scope; no substitute practitioner is accepted without my agreement.

□ I understand no photos, marketing use, or audio/video recording are included in this consent.

This draft does not waive negligence claims, statutory rights, or the practitioner's duties. A separate process is required for minors.

Client signature

Date

Practitioner signature

Date

6. Practitioner record of changes

Record the proposed change, explanation, client's choice, and time. Do not infer permission from silence.