Mind Body Spirit
Healing Arts Sanctuary
Gina K Nelson, E.H.T. Certified Energy Healing Therapist
Disclosure and Release Form
Welcome, I am honored to be on this healing path with you and to create a safe space for you to achieve your goals for your well being. Energy Healing is a hands on healing modality that utilizes “Chi” or the life force energy of the subtle nervous system to promote health, healing and a sense of well being. Energy Healing can stimulate the nervous and subtle nervous system, clear blocked or stagnant chi pathways and meridians, stimulate the natural immune response, ease emotional trauma, offer deeper knowledge and insight of Self, create renewed balance and relaxation and deeply integrate the body/mind/spirit. Below you will find information and policies to help you understand more about Energy Healing Sessions and give you more clarity about our time together. During our sessions we will discuss your physical, psychological, emotional and spiritual health needs and goals.
Energy Healing is a hands-on technique using the body’s own Human Energy System to achieve physical, emotional and spiritual wellness. Our body can hold and trap energy and emotions from our life experiences. The release of these energies and emotions can bring about deep healing. Our sessions may include energy healing (fully clothed), breath work, guided imagery, and movement. You may experience healing shifts and transformations in your body, beliefs or energetic system during our session together or in the days or weeks following.
-A 24-hour notice of cancellation is requested.
-After our session try to wait at least 10 minutes before driving, drink plenty of water, eat healthy foods and try to take time to rest and relax. Try to postpone confrontations for 24 hours.
-You are welcome to call me if you have any questions after our session.
-All information shared on your intake form and during our sessions will remain strictly confidential unless there is a situation involving harm to yourself or another.
-Please maintain appropriate care and treatment with your medical doctor, chiropractor, acupuncturist, psychologist or other caregivers so that you may create an effective network of health care. Please inform your healthcare providers about your energy healing.
I, the undersigned, understand that Gina K Nelson is certified by The Lionheart Institute of Transpersonal Energy Healing as an Energy Healing Therapist, she is also a Yuen Method Practitioner and a Reiki Practitioner. She is not a physician, psychologist or licensed as psychotherapist. I, therefore, am not seeking diagnosis for any mental or emotional disorder, nor am I seeking marriage counseling. I am voluntarily requesting holistic counseling, energy healing, spiritual understanding, behavioral improvement or self-development. I understand that Energy Healing is not licensed by the State and that this work is considered complementary to other forms of health care. Such practice is fully permissible under the California State Senate Bill SB577, Bus & Prof Code 2053.6. I take full responsibility for how I choose to interpret and implement all information and experience derived from any sessions I may have with Gina. I am responsible for my own life, choices and actions, which include financial responsibility agreed to by my spouse or family, if applicable.
I, the undersigned, therefore, release Gina K Nelson from all liability, demands, claims, actions, loss, costs, risk, or compensation for indirect, incidental or consequential damages whether physical, mental or practical, resulting from initial and succeeding sessions. I have read this agreement and fully understand its contents. I am aware this is a release of liability and a contract between Gina K Nelson and myself and I sign it of my own free will. I have received a copy of this discloser and release form.
Please note that California Senate Bill SB-577, which was enacted in September 2002, enables alternative and complementary health care practitioners to provide and advertise their services legally in the state of California.
Signature of Client/parent/guardian: Date: ______________
Printed Name: ____________________________________________________
Mind Body Spirit
Healing Arts Sanctuary
Gina K Nelson, E.H.P. Certified Energy Healing Practitioner
Confidential Client Intake Form
Home # (_____)_____________Work # (_____)_______________cell#( _____)___________email:____________________
Birthdate____________ Age_____ M___ F___ driver’s license#______________________________exp date______
Relationship status_________________________Spouse/partner name________________________________
Names & ages of children__________________________________________________________________
Who do you count on for support?______________________________________________________________
What other kinds of healing/therapy/counseling work are you receiving now? ______________________________________________________________________________________________________________________________________________________________________________________
Have you ever been in therapy/counseling? ____ yes ____ no How long? ________
Reason for coming/ major issues? _____________________________________________________________
Other issues or complaints?_____________________________________________________________________
How long have you had this condition/s?___________________________________________________________
What do you believe caused this condition/s?________________________________________________________________________
List any previous diagnoses and treatments you have received for your present condition/s._________________________________________________________________________________________________________________________________________________________________________________
List surgical operations and dates, broken bones, accidents, and dates, history of serious physical or psychological illness. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Current or past use of any prescription or non-prescription drugs?
___yes ___no please list all current drugs and doses:_______________________________________
Habits: alcohol usage ____________________ drugs (which ones) ______________________
Tobacco _____________ Food_____________________ Exercise (how often)______________
Please comment about your nutritional habits( i.e balanced diet, eating not eating well etc:__________________________________________________________________________________________________________________________________________________________________________________________
Physical or emotional disorders in self/family members?_______________________________________________________________________________________________________________________________________________________________________________
What is your goal for our session today?
Do you have a longer term goal for your emotional, physical, spiritual self? ___________________________________________________________________________________________________________________
Is there anything else important you think I should know?________________________________________________________________________________________________________________________________
In case of emergency contact:
I certify that the all information is true and correct to the best of my knowledge.
Print your name ______________________________________Signature______________________