Your Name*

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This appointment is for:*

Me
My minor child
My pet
Relationship healing
Business prosperity work
Feng shui - home or office

Name of Minor Child*

Full Name Date of Birth

Name of other person in relationship*

Full Name Date of Birth

Name of Pet*

Name Age

Your Address*

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Your Phone*

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Your Occupation

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Your Date of Birth

Who can we thank for the referral?*

(how did you hear about my services?)

Current condition and/or symptoms of the subject of this session:*

Please rate each symptom on a scale of 1-10, with 10 being the worst.

Medical History of subject of session

Please list on a separate line all current diagnosis, current prescriptions or treatments for each.

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Any other pertinent medical history, including surgeries, implants, etc.

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Please check if any of the following apply to the subject of the session:*

I understand that if any of these answers change during the course of our sessions, I will update you immediately.

COVID information - are you vaccinated, boosted, and have you experienced and/or been diagnosed with Covid-19?*

Please share information about any significant trauma experiences during childhood or adulthood.*

Please share information about current and/or former religious / spiritual groups / practices.*

Anything else about your situation that you think is important:*

STATEMENT OF RISKS, ASSUMPTION OF RISKS AND RELEASE:*

I, THE UNDERSIGNED FOR MYSELF OR ON BEHALF OF ANY MINOR INDICATED BY ME BELOW, AGREE TO THE FOLLOWING: I understand that Energy Healing / Pranic Healing® practitioners are not licensed physicians or surgeons, and Pranic Healing® treatments are not licensed by the state but are complementary to healing arts services licensed by the state. That Energy Healing / Pranic Healing® practitioners do not physically touch the recipient’s body, diagnose diseases, prescribe any drugs/substances or make any health claims or guarantee any outcomes. That although this is a healing modality, and the goal is to improve my health, I understand that unexpected or unanticipated results may occur. That Energy Healing / Pranic Healing® is not meant to replace conventional medicine but rather to complement and enhance it. If symptoms persist, I agree to consult a medical professional. I agree to provide updated and current information in the event any the status of any of the conditions (listed above) changes. I understand that I am responsible for my own safety. I expressly accept all risks associated with this activity and voluntarily assume full responsibility for all the consequences of my choosing to engage in Energy Healing / Pranic Healing®. I hold Heart to Heart Healing, LLC and Liza Burney harmless for any death, injury, damage, or loss which I (or any minor on whose behalf I sign this contract) might suffer as a result of participation in this process, including any injuries or damages which result from another's negligence or fault. I have read and accept the terms of this liability disclaimer agreement.

ADDITIONAL LIABILITY RELEASE AGREEMENT FOR PARENTS of MINORS*

As a parent or legal guardian of a minor under 18 years of age who will participate in and receive Energy Healing / Pranic Healing® treatments; I have read this contract and document and sign this release on his or her behalf. I understand and agree that every provision in this contract applies to the minor on whose behalf I sign this contract, just as it would apply to me if I were signing it for myself.

Initial Session 1.5 hours

Price:

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