Client Intake Form and Waiver

Please answer the questions to the best of your ability. The information collected can be used in sessions to assist in addressing issues and in directing session focuses.

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Name
Address
Please check any symptoms from the following list
Do you currently smoke?
Do you drink alcohol?
Are you happy with your weight?
Your general state of Health is
Your general state of Stress is

Informed Consent to Treatment

Please read and sign the following statements:
I understand that I give my consent to the practitioners of Radiant Bioenergetics to conduct a session of Natural Bioenergetics/HK™, and/or other natural therapies such as SCENAR, essences, nutritional consulting, Matrix Energetics, etc. as may be appropriate, with me.

I understand that the practitioners of this health centre are certified in their disciplines and will use only natural, non-invasive methods of assessment and therapy. I am aware that a healing reaction (commonly called “detox reaction”) may occur. It is usually mild and will pass in a few days with rest and water. I may experience tiredness, irritation, digestive disturbances, soreness, a mild fever or other symptoms. If I have any concerns with a reaction I will contact my practitioner immediately.

I also understand that Natural Bioenergetics/HK™ do NOT directly treat any physical diseases, disorders, ailments, etc. Matrix Energetics and Natural Bioenergetics/HK™ work is for the body’s underlying energy system.

I also understand that Natural Bioenergetics/HK™ is NOT psychotherapy. It deals with emotional issues on an energy level, not a conscious level. It does NOT deal with, nor is it related to parapsychology.

I understand that Natural Bioenergetics/HK™ is a complementary health program and does NOT diagnose disease or conditions, nor does it replace the care of your physician. It is your responsibility to consult your physician about any medical problem or concern that you become aware of.

I understand that any advice given to me as a client at Radiant Bioenergetics is not mutually exclusive from any treatment or advice, I may be given by another health care provider. I understand that I am at liberty to seek, or continue, medical care from any other health care provider qualified to practice. I understand that the practitioners reserve the right to determine which cases fall outside of their scope of practice and an appropriate referral will be recommended.

I understand that I am accepting or rejecting this care by my own free will. No employee or practitioner at Radiant Bioenergetics is suggesting to me to refrain from seeking the advice of another health care provider.

I understand that the services offered are not covered by __Radiant Bioenergetics__ and are payable at time of service. Submission to any insurance plan that may provide coverage for the service is my sole responsibility.

I understand the24 hours’ notice is required for appointment cancellation; otherwise, I will be responsible for the cancellation fee of 100% of the time booked.

I understand that any therapies recommended will be explained to me in full by the specialist and that I will give consent to treatment based on informed consent.

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