CLIENT CONSENT FORM

I, the undersigned, understand that:  

 

1. Kathy Stevens ("this Practitioner") is not a medical doctor, psychologist, or psychiatrist. This practitioner does not claim to, nor does she represent to be, a licensed health care provider of any sort. 
2. This work is not offered as a replacement or substitute for health care treatment with a licensed and qualified health care provider, but rather as an optional, complementary service. 
3. This practitioner does not take any legal or clinical responsibility for the health or welfare or health care of the undersigned ("the Client"). The licensed health care providers, which the Client has engaged, are the only entities that are legally and clinically accountable for the health and welfare of the Client, even if a licensed health care provider refers the Client to this Practitioner. 
4. This Practitioner does not offer diagnosis, treatment or cure for any physical, mental or emotional health care problem, disorder or illness.  Education, empowerment, and nutritional recommendations are the concentration of this Practitioner’s business. 
5. This Practitioner offers the Client an education and environment that may promote a natural and healthier lifestyle, which may bring about a greater ability to meet life's challenges. 
6. All information given to this Practitioner is confidential. Information will only be disclosed with written consent of the Client. However, if the Client discloses the potential of the Client harming him/her and/or others, or if information is revealed indicating the potential or actual harm of a child, this practitioner is legally (and morally) bound to disclose this information to the appropriate authorities. 
7. No third party, including assistants or members of the Client's family, if the Client is over the age of 18 years, may be present during the course of a session with the Client without the express consent of the Client and this Practitioner. 
8. The Client will always remain fully clothed during a session. 
9. Only respectful touch of the Client's body may be used, and only with permission of the Client. 
10. Any work done with anyone under the age of 18, will only be done with the approval of parent or legal guardian, and any and all sessions will take place only with a parent or legal guardian present. 

 

I have read and I understand all the statements above, and I agree to these terms. I certify that I am under, or will seek, the care of a licensed health care provider, if I believe I have, or am aware that I have a serious mental, physical or emotional problem or illness. I agree that I will not terminate conventional and/or alternative treatment with a licensed and qualified health care provider(s) as a result of this work. 


I, the undersigned, do not hold Kathy Stevens legally or clinically responsible for any aspect of my physical, mental or emotional health or care thereof. 


Client’s Name (printed) _____________________________________


Signature ______________________________________________         Date ___________________