Ph#: 407-908-4918 / SJ@HealingSelect.com
Please read this letter prior to coming to the
healing. You will be required to sign this form prior to the first healing
session.
Client Information Letter and Consent
for Treatment
Scope of Practice
My
name is Sundeep Jay and I am a graduate of the Barbara Brennan School of Healing -
which is a 4 year school specializing in the teaching of energy healing on
individuals. The healing I provide is complementary to other options that are
available in the health industry. I do not medically or psychologically diagnose or
prescribe treatment and or medical drugs. If you have a physical injury or a disease
condition, I ask that you be in the care of a licensed medical professional. I do
not advice you to discontinue any medical or psychological treatment you may be
receiving.
Type of Healing Work
The
Brennan Healing Science that I apply helps to clear and charge the human energy
field which surrounds ALL living and inanimate things. The work I will be
accomplishing helps remove energetic blocks that may lead to dis-ease and to enhance
the body's natural healing capability. I will be doing energy healing work both with
my hands on the body and also through the Human energy Field which surrounds the
body. This work does not require me to place my hands on your body in order for the
healing to work. The work is done with you being fully clothed and lying on the
healing table or sitting in a chair. The exact location of the gentle hand
placements will be discussed prior to the healing. In general, my hands are placed
on ALL of the 7 energy centers (called chakras) that are located throughout your
spinal cord and also in the place of discomfort. Please let me know if any area is
sensitive. We may also explore areas that influence your state of well-being,
such as your health history, life stressors, belief systems, your family, childhood
history, and relationships. Everything you share is confidential. I do discuss
clients (without using real names) with my professional supervisor or peers for the
purpose of continuing education. THIS IS NOT MASSAGE THERAPY, NOR IS THERE ANY FORM
OF MUSCLE AND OR BODY MANIPULATION. The Sessions will support and facilitate
physical, emotional, mental and spiritual health & healing.
Self care is
an extremely important part of this work and it is your responsibility during our
work together. If at any time during the session you are uncomfortable, please
inform me immediately and I will stop the healing work. I also recommend that you
refrain from using alcoholic beverages 24 hours prior to and following our
session.
ACKNOWLEDGEMENT, CONSENT, CLIENT
PRIVACY RIGHTS
I have read and understand the above disclosure
regarding the services offered by Sundeep Jay.
We have discussed the nature
of the services to be provided including information that Energy Healing is a
holistic complementary and integrative energy based therapy that is accomplished
through the use of contact and/or non-contact touch. I understand that he is not a
licensed physician, psychologist or a massage therapist and that his services are
not licensed by the State of Florida. I understand it is my responsibility to
maintain a relationship for health with a medical doctor, if I so desire. I further
understand that the above named is not trained to diagnose illness, make
recommendations involving pharmaceutical drugs or surgery, or handle medical
emergencies.
I have read and understand the above disclosure regarding privacy
policies and confidentiality, and that experiences during these sessions are
confidential, but subject to the usual exceptions governed by the laws of the State
of Florida and other federal laws and regulations.
I have been informed that
Sundeep Jay will not diagnose nor prescribe drugs for any condition that I might
have nor does he make any specific claims regarding results from the Healing
Sessions that I receive.
My questions have been answered to my satisfaction
regarding my Energy Healer's background, a Healing Session, and what I might expect
from this and future session.
* Except in the case of gross negligence or
malpractice, I or my representative(s) agree to fully release and hold harmless,
Sundeep Jay from and against any and all claims or liabilities of whatsoever kind or
nature arising out of or in connection with my session(s).
I fully
consent to use the services offered by Sundeep Jay by signing below:
Signed:
_____________________________________________ Date:
____________________
Print Name:
___________________________________________________________________
Address:
____________________________________________________________