CLIENT INTAKE FORM 

Please complete this questionnaire honestly and as thoroughly as possible. 

This is a confidential record of your medical history and will be kept in the office. Information contained here will not be released to any person except when you have authorized us in writing to do so, or when required by law. 

If you are female, are you currently pregnant? (Please advise if you become pregnant during our time working together.)
Do you have any sensitivity to sound or vibration?
Do you have any difficulty lying on your front or back?
The main stressor in my life is:
What level of stress are you experiencing in your daily life right now?What level of stress are you experiencing in your daily life right now?

Please read and sign the waivers below:
(I agree that e-signing my signature is a valid form of agreement and acknowledgement.)

WAIVER & RELEASE FROM LIABILITY FOR ALL SPIRITUAL ARTS 

SERVICES & SPIRITUAL COUNSEL 

 

I acknowledge that Brandon Loveladdy and/or Chelsea Loveladdy and Orange County Reiki & Sound Transformations are Spiritual Arts Practitioners & Metaphysical Ministers, and are a private practice for the purpose of providing mental, emotional, physical, and/or spiritual support using various Spiritual Art mediums. 

I also acknowledge that Brandon/Chelsea Loveladdy are not medical doctors or mental health care professionals, and thus accordingly cannot and will not provide me with medical advice or psychological advice. I will rely on my own medical practitioner or mental health professional for advice for medical or psychological advice. I recognize that Spiritual Arts are only one factor in the management of my health. I also recognize that ultimately it is up to me as to whether I choose to follow the sharing of information and skills provided by any practitioners acting on behalf of Orange County Reiki & Sound Transformations, and that it is highly advisable to consult with my medical or mental health professional prior to so doing. For the safety of all concerned parties, Brandon/Chelsea Loveladdy have the right to refuse service to anyone who does not comply with our terms and agreements or who they consider may need professional medical treatment that they do not offer. I give Brandon and/or Chelsea Loveladdy the right to utilize hands on physical treatment during the Spiritual healing and other healing arts modalities. I understand that this hands on energy healing will not be offered if you have advised Brandon or Chelsea beforehand. Therefore if you have not advised us not to touch you, you waive the right to make legal or defamatory claims regarding this physical interaction.

Brandon/Chelsea Loveladdy facilitate only Spiritual Arts sessions and services. They will respond to my inquiries by providing positive reinforcement and appropriate feedback. I acknowledge my overall responsibility to advise them with respect to my levels of comfort or discomfort and any other information, which might influence their support of me. In consideration of the services, information, and support I have received or will hereafter receive from Orange County Reiki & Sound Transformations, I hereby hold harmless Brandon/Chelsea Loveladdy (and their heirs) and Orange County Reiki & Sound Transformations from any or all liability in consequence, or supposed consequences of such services, information and support given, and release and waive all claim for damage howsoever incurred or to be incurred, as a result of such services, information and support. I release the right to legal counsel, arbitration, settlement, and/or litigation. This Release shall be effective and binding upon my heirs, next of kin, executors, administrators and assigns. 

I have read this Release prior to signing and I understand its effect. I am aware that by signing this Release I am waiving certain legal rights, which I or my heirs, next of kin, executors, administrators and assigns may otherwise have had against Releasees. 

SPIRITUAL COUNSEL & SPIRITUAL ARTS INFORMED CONSENT 

 

I fully understand that spiritual wellness counseling, Spiritual Arts modalities (Sound Baths, Reiki, Spiritual Healing, Breathwork, Kambo, Meditation Instruction, Space Clearing, Trance Mediumship, Initiations, Courses, products and services, etc.) are not replacement or substitute for medical examinations and/or professional treatment and diagnosis. I agree to see a physician for physical ailments, and/or a psychotherapist for mental/emotional ailments that I may have now, or in the future. Due to the fact that a spiritual counselor and/or Spiritual Arts practitioner must be made aware of any physical conditions, I have stated all known medical/mental/ emotional conditions, and take it upon myself to keep the therapist updated on my physical and mental/ emotional overall wellbeing. 

I understand that any remarks which are made which can be construed as aggressive or illicit will result in the immediate termination of the session, and I will be fully liable for payment of the scheduled appointment. 

I understand and respect that payment is due at the time of treatment. I agree to give 24 hours notice of cancellation of appointment, unless in cases of extreme emergency. All cancelations must be rescheduled within 14 days, with exception of emergency. If less than 24 hours notice is provided, I agree to be charged for 50% of the appointment time missed. 

I have carefully read and fully comprehend and agree to all of the above, as well as the Terms & Disclaimers on OrangeCountyReiki.com, and I have answered all the questions in the Client Intake Form honestly and completely.