The Beloved Heart Source, Susanah Magdalena Proprietress, Westminster, CO 80031
www.thebelovedheartsource.com email@example.com 303.917.1243
© 2018 Susanah Magdalena (aka Tami Harms) All rights reserved.
Client Agreement and Disclosure Statement
Thank you for your interest in working with me as a client either in person or at a distance using the phone/Skype/email, whichever is applicable. I am providing you with the following information so you can make an informed choice about your decision to engage my services. Please read this information carefully and let me know if there is any part you do not understand.
SERVICES OFFERED/THEORETICAL APPROACH
I offer my services as a complementary and alternative health care practitioner under Colorado’s Natural Health Care Consumer Protection Act. I work with clients in a number of areas, including, overall health, life issues, spiritual business mentoring, and energy and spiritual wellness. My goal is to help my clients align with their highest potential using intuitive skills to help turn struggles and challenges into new learning and growth opportunities. My focus with a client is to work with the whole person, using a variety of complementary and alternative approaches. The approaches I use primarily in my practice are based on the newly emerging field of energy clearing and include, the teaching of classes, mentoring on the individual spiritual level as well as for successful spiritual businesses, private sessions of channeled messages, the use of scent to trigger the amygdala, and more (collectively the “Energy Methods”). You have the option of using individually or collectively any of the Energy Methods I offer as part of our work together.
The Energy Methods are designed to create a synergy of well-being of the body, mind and soul. This is to assist the energy bodies to the return of harmonious state of the soul. This has the potential to boost health, increase vitality and to restore the body’s natural energy patterns. With these Energy Methods, I assess the energetic impact of how thoughts, beliefs and emotions can influence health and well-being of the client. The prevailing premise of the Energy Methods is that the flow and balance of the body’s electromagnetic and subtle energies are vital for physical, emotional, mental and spiritual health as well as for fostering well-being on all levels.
Although the Energy Methods appear to have promising emotional, spiritual, mental and physical health benefits, they have yet to be fully researched by Western academic, medical and psychological communities. Therefore, the Energy Methods may be considered experimental and the extent of their effectiveness, as well as their risks and benefits, are not fully evaluated and known.
NATURE OF THE RELATIONSHIP
Please be advised I offer my services solely as complementary and alternative health care practitioner. You should discuss any recommendations I make during your session with your primary care physician, obstetrician, physician, obstetrician, gynecologist, oncologist, cardiologist, pediatrician, or other board-certified physician.
The Energy Methods are self-regulated and the State of Colorado does not license, certify, or register complementary and alternative health care practitioners. While I have extensive experience as a healing arts practitioner, I am not a psychologist, psychotherapist, physician, or other licensed health care professional. Under Colorado’s Natural Health Care Consumer Protection Act, I can offer my services subject to the requirements and restrictions that are fully described therein.
OUTCOME EXPECTATIONS/RISKS & BENEFITS
While clients report positive outcomes in using my services, please note that it’s impossible to guarantee any specific results and we don’t know how you will personally respond to using the Energy Methods. However, we will work together to achieve the best possible results for you. Participation in sessions can result in a number of benefits to you, including improvement and/or resolution of the specific concerns that led you to seek my services. While the Energy Methods are considered gentle and non-invasive, it’s possible in our sessions together, or on your own between sessions, to experience some physical discomfort or emotional distress that can be perceived as negative. It is also possible to experience some emotional distress and physical discomfort related to stressful experiences you may have had earlier in your life. You agree to promptly inform me if you experience any emotional distress and/or physical discomfort during our work together, particularly between our sessions. If appropriate, I can help refer you to an appropriate professional health care provider for further assistance.
EDUCATION AND TRAINING
I hold an Associates Degree in Travel and Tourism from Tulsa Jr. College. I hold a Certificate of Completion in Emotional Freedom Technique (EFT) and am a Reiki Master/Teacher. I have studied extensively for 20+ years with various teachers regarding the use of Young Living’s Essential Oils. I have taken numerous courses and have studied aspects of spirituality and metaphysics for 25+ years.
OTHER IMPORTANT INFORMATION
I am covered by liability insurance applicable to any injury caused by an act or omission by me in providing my complementary and alternative health care services pursuant to this Agreement.
ACKNOWLEDGMENT & CONSENT TO RECEIVE SERVICES
By signing this document you agree that I have disclosed to you sufficient information to enable you to decide to undergo or forgo the services I offer. You have considered all of the above information and have obtained whatever information or professional advice you deem necessary to make an informed decision. By signing this document you understand I am offering my services solely as a complementary and alternative health care practitioner and our relationship is not to be construed as medical treatment, psychotherapy, psychological counseling, or any type of therapy, nor is it a substitute for these services. Due to experimental nature of the Energy Methods, you agree to assume and accept full responsibility for any and all risks associated with using the Energy Methods. You acknowledge that we have discussed and you understand, and agree to and have received a copy of my Office Policies & Procedures, which is attached hereto and incorporated herein by reference.
You understand it is your responsibility to maintain a relationship with a health care professional. Further, you understand your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. You represent that you are competent and able to understand the nature and consequences of the proposed sessions and agree to be personally responsible for the fees related thereto. You have discussed with me the nature of the services to be provided and you understand that I’m not a licensed, registered, or certified health care provider in the State of Colorado. You agree and understand that this Agreement is intended to be a complete unconditional release of liability and assumption of risk to the greatest extent permitted by law. By signing in the space provided below, you knowingly, voluntarily, and intelligently assume these risks and risks and agree to irrevocably release, indemnify, hold harmless and defend Susanah Magdalena (aka Tami Harms) and her agents, representatives, consultants, and employees from and against any and all claims of whatsoever kind or nature, and for any loss, damage, or injury, including but not limited to, financial, personal, emotional, psychological, medical, or otherwise which you may incur arising at any time out of on in connection with your sessions.
By signing in the space below, you acknowledge you have received the information described in Paragraph (a) of Subsection 7 of Colorado’s Natural Health Care Consumer Protection Act all of which is provided in this Client Agreement and Disclosure Statement. Per Colorado law, I will keep an original signed copy of this Client Agreement and Disclosure Statement in my records for at least two (2) years.
Name (Printed) Name (Signed)
If you are submitting this Agreement electronically, typing your name in the space provided above will be considered your signature and constitute your acceptance and understanding of this Agreement.
POLICIES & PROCEDURES
ATTACHMENT TO CLIENT AGREEMENT & DISCLOSURE STATEMENT
With the exception of special situations described below, I will keep our work together confidential. I cannot and will not tell anyone else what you have told me, or even that you are using my services without your prior written permission. You may direct me to share information with whomever you choose and you can change your mind and revoke that permission at any time.
Although I am not a licensed professional health care provider, I choose to be in alignment with general ethical standards by adhering to the following legal exceptions to confidentiality:
1. If I believe the client is in imminent danger of hurting herself/himself
2. If I believe the client is threatening serious bodily harm to another
3. If I believe that a child, elderly or disabled person is being abused
4. If I am presented with a legitimate court order to present testimony in a legal proceeding
5. If a client fails to pay for services requiring action to collect fees due
SESSIONS and PROFESSIONAL FEES
Sessions and Professional Fess vary. Please ask if there are questions or if clarification is needed.
Sessions may be paid for by personal check, cash, or credit card. I do not bill through insurance so my work is on a fee for service basis. Payment is expected prior to the appointment or at the time of service, unless previous arrangements have been made. Please notify me right away if a problem arises regarding your ability to make payments.
Scheduling of appointments involves the reservation of time specifically for you. Please allow a minimum of 24-hour advance notice for rescheduling or canceling an appointment. The full fee may be charged for missed appointments without such notification.