Disclosure Form Joan

8/10/2019 Disclosure Form Joan

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Joan Cremin: Spirit Guided Energy Healer Certified Reiki Master

Confidential Client History [email protected]

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E#M*+, *ddress

-ame: Home pone: /ork pone: Cellpone:

*ddress: City State: 0ip:

)ate of 1irt: 2 3f Cildren:

Emergency Contact -ame: Home: /ork:

Cell:

Ha4e you recei4ed energy 5ork 6efore7 8es -o Reason:

/at type7 RE+9+ E-ERG8 ME)+C+-E 3ter

Generally o5 did it go for you7

/ere you uncomforta6le in any 5ay7 8es -o +f yes please descri6e

/at did you like te most a6out te session;s<7

Reason you are coming for Energy Healing today7

*ny pre4ious attempt to address tis issue7 8es -o Results7

)o you a4e oter issues tat you 6elie4e EH 5ould elp 5it7

=lease gi4e a 6rief account of te istory of 5at 5as going on in your life at te time and tede4elopment of your complaint ;from onset to present i.e.: di4orce>deat>career cange etc.<

Gi4e your tree top goals for our sessions togeter:

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=lease rate your distress due to your issue: " is feeling good>does not 6oter you "& mostupset you can 6e or a4e e4er 6een.



)istress: today ;please igligt< " ( ? $ ' ! % "& /eek *4g. " ( ? $ ' ! % "&

=lease descri6e distress and possi6le cause.

/at ? tings 5ill 6e 6etter or different in your life if tis pro6lem 5as gone:

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Medical History

*re you currently undergoing medical or psycological treatment for te a6o4e issue7 8es -o

+f so 5ere7 )r.As name7

Ha4e you e4er 6een treated for emotional pro6lems7 8es -o +f yes are you currentlyrecei4ing treatment or counseling7 8es -o 1y 5om7

)o you suffer from any medical conditions or pysical pains7 -ote location on your 6ody andonset>istory:

*re you on pain medication7 8es -o

Ha4e you ad any prolonged illness7 8es -o ;+f yes 5at illness<

Ho5 are your sleeping patterns7

)o you need any eBtra support 5it pillo5s to keep you comforta6le 5ile lying do5n on temassage ta6le7 8es -o +f so 5ere7 Head -eck 9nees 3ter

*t any time if tere anyting else you need to make you comforta6le please let me kno5.

=ysical =ain: today ;no pain< " ( ? $ ' ! % "& ;6ad< /eek *4g. " ( ? $ ' ! % "

/en are your symptoms 6etter7

/en are tey 5orse7

/en are tey gone7 ;/at are you doing7 3r not doing7<

/H* 3= ( DRH8S MEH3) =R3F+,ES )3 83 RE,*E 3 HE M3S *-) /H87



+s tere anyting else you 5ould like me to kno57

)o you a4e any uestions a6out Energy Healing7 8es -o

+f yes =lease descri6e:

*s in most ealing modalities it is rare tat one treatment 5ill cure ones ailments. Energy Healingis no different. Energy Healing does a4e te potential to make profound canges in oneAsspiritual and emotional life 5ic can elp support you on your pat to5ards self ealing and5oleness. ere are no promises or guarantees of miracle cures for any condition. e maority

of people Joan as done ealing sessions 5it a4e eBperienced cange in teir condition andteir li4es as 5ell as an increased sense of 5ell 6eing. Since spiritual transformation acti4itiescan take many forms 6ot pysical emotional and mental it is igly recommended tat yousupport any 5ork done 5it Joan 6y consulting 5it your pysician.

+ ;name< IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII gi4e te practitioner Joan Cremin permissionto use Spirit Guided Energy Healing tat uses ligt non#in4asi4e and placement tat focusesmainly on te cakra system tat are located along specific points of te 6ody. + understand tat +5ill remain fully cloted trougout te entire session as + relaB on comforta6le and paddedmassage ta6le. 1y signing 6elo5 + agree to participate in te non#in4asi4e ands#on ealingtecniues as part of te session 5ork and + agree tat Joan Cremin 5ill not 6e lia6le or

responsi6le in any 5ay for te outcome of tis practice.

)isclosure:

*s part of my session 5ork 5it te =ractitioner + understand tat + 5ill recei4e a Spirirt GuidedEnergy Healing session also kno5n as Reiki 5ic is a tecniue referred to as a type of energyealing tat 5orks 5it te cakras. EH appears to a4e promising mental spiritual and pysicalealt 6enefits. e pre4ailing premise is tat Reiki uses te ancient cakra system to relie4eemotional stress and pysiological 6locks and 5orks 5it te energy system 5it gentle non#in4asi4e and placement. 1y signing tis document + understand tat Reiki could 6e consideredeBperimental and + agree to assume and accept full responsi6ility for any and all risks associated

5it using Energy Healing as part of my participation in te ealing sessions. Furter + agree andunderstand tat te information presented in my sessions is only for my o5n personal use.

*ll ealing sessions pro4ided 6y Joan Cremin are strictly for spiritual ad4ancement only. Healtand 5ellness can 6e a pleasant result of te 5ork 6ut it sould not 6e misrepresented asprofessional counseling or medical treatment. -o guarantees are offered or implied. 1yparticipating in te ealing session + understand tat it is possi6le tat emotional or pysicalsensations or additional unresol4ed memories may surface 5ic could 6e percei4ed as negati4e



side effects. Furter + understand itAs possi6le to eBperience some emotional distress andpysical sensations related to prior life eBperiences. e clinical reports from energy terapiessuc as Reiki so5 no additional side#effects 5en used appropriately. Emotions may continueto arise after te session and + understand +Am encouraged to discuss suc emotions 5it myappropriate ealt care pro4ider. +n addition + understand pre4iously 4i4id or traumaticmemories may fade. is could ad4ersely impact my a6ility to pro4ide detailed legal testimonyregarding a traumatic incident. + agree to take full responsi6ility for my self#care in te emotionalmental pysical and spiritual dimensions of my life.

Joan Cremin takes no responsi6ility for any client 5o takes action on ad4ice gi4en in a session5eter formal or informal. +t is solely te clientAs responsi6ility if e or se cooses to undertakeany action on ad4ice gi4en. e information presented during my session including learninganyting a6out Reiki is pro4ided only as general information and is not intended to represent tatReiki is used to diagnose treat cure or pre4ent any disease or psycological>mental ealtdisorder. Reiki is not a su6stitute for medical or psycological treatment. + understand tat tepractitioner ;does not recommend + stop seeing any of my ealt care professionals or usingprescri6ed medicine if any 5itout consulting 5it te appropriate ealt care professional e4enif after recei4ing an Energy Healing session or any oter energy 6ased tecniue it appears or

indicates suc medicine or terapy is unnecessary. *ll ealing sessions are complimentary andnot alternati4e and sould ne4er replace con4entional diagnosis or recommended treatment 6yyour ealt care professional.

*ny stories or testimonials presented during my sessions do not constitute a 5arranty guaranteeor prediction regarding te outcome of an indi4idual recei4ing an Energy Healing session duringor after te session for any particular issue. Furter + understand te practitioner makes no5arranty guarantee or prediction regarding any outcome for me during or after te session forany particular issue. e practitioner accepts no responsi6ility or lia6ility 5atsoe4er for te useor misuse of te information pro4ided during te sessions. + understand te practitioner stronglyad4ises tat + seek professional ad4ice as appropriate 6efore making any ealt decisions.

e =ractitioner ;Joan Cremin< as disclosed to me tat se is not a licensed pysician or mentalealt pro4ider. Joan Cremin as te follo5ing education training eBperience and oterualifications regarding ser4ices pro4ided:

". Certified Reiki Master =ractitioner.

(. Joan as also recei4ed some training in =olarity erapy.

?. Joan is a student of e Rys Metod =rofiles.

+ ackno5ledge tat + a4e 6een gi4en te opportunity 6y te =ractitioner to ask uestionsregarding any aspect of tis *greement. + understand tat 6y signing 6elo5 + ackno5ledge tat +a4e carefully and completely read and fully understand all aspects of tis *greement and + agreeto all of te terms and conditions stated erein. Furter + agree and understand tat tis

*greement is intended to 6e a complete unconditional release of lia6ility and assumption of risk tote greatest eBtent permitted 6y la5. is *greement sall 6e 6inding upon me and my eirslegal representati4e and assigns.



+ represent tat + am an adult under te la5s of te State of my residence and + a4e te rigt toenter into tis *greement. +f + am a minor + sall a4e my parent or legal guardian consent to and

oin in tis *greement 6y signing in te space pro4ided 6elo5.

=lease indicate your acceptance and agreement 6y signing in te space pro4ided 6elo5.

Client -ame ;=rint< )ate

Client Signature =arent>Guardian Signature ;Signature is reuired if client is under "! years old<

Documents

Disclosure Form Joan