Client Intake Form

Infinity Wellness Corporation

CONSENT FOR ENERGY HEALING SESSIONS

• My consent to energy healing sessions by Beverly A. Hann.
• My understanding is that participation in the sessions is voluntary.
• My understanding is that I can stop or delay further sessions if I so desire.
• My understanding is that Beverly A. Hann is an independent energy healer and is not employed by the insurance company or any other facility.
• My understanding is that energy healing sessions are not a substitute for medical examinations and/or diagnosis for any ailment that I might have.
• That I hereby release Beverly A. Hann or its agents, officers and employees from any liability with respect to any injury or adverse reactions that I may suffer before, during, and after the healing energy session.
• My consent to the electronic transmission of information obtained before the energy healing session including the intake form and consent form. This electronic file will remain the property of Beverly A. Hann and will not be released to any third party without your consent.
• I consent to the payment of energy healing sessions by Visa, MasterCard, or interact at a rate of $300.00 per session. I understand that I am fully responsible for the cost of my session before my session occurs.
• I understand that if I miss or cancel an appointment without a call to the office 24 hours in advance of the appointment time that a fee of 100% of the cost of the booked session will be charged for the missed appointment.
• Limits of Confidentiality: efforts to maintain client confidentiality and privacy of information are upheld. However, there remain some instances where information can be released. This include:
• 1) Information that identifies that the client or someone else is eminently at risk for harm. This must be reported to the persons who can keep the person safe (i.e. police, intended victim)
• 2) Information relating to an indication that a child is at risk for harm. This will be reported to the Children’s Aide Society and involve CAS protocols.
• 3) Information regarding the report of abuse by another regulated health care professional as listed in the Regulated Health Professions Act, or abuse by another licensed professional, will be shared with the licensing body of the professional.