Patient Forms

Name *

First Name

Last Name

Authorization *

I authorize and request my practitioner to carry out Energy Healing sessions.

Understand *

I also understand that while the course of my session is designed to be helpful, Shari can make no guarantees about the outcome of my session. Further, this process can bring up uncomfortable feelings and reactions such as anxiety, sadness and anger. I understand that this is a normal response to working through unresolved life experiences and that these reactions will be worked on between my practitioner and me.

Consent *

I am at least 18 years old, the age of consent to make any decisions as to my person and treatment.

If In-Person *

I understand that if my session is done in-person the practitioner may lay her hands lightly on my body, particularly on head and over the heart and stomach. However, this will be done only with my consent. I will remain fully clothed during my session.

Distance Therapies *

I understand that Shari provides healing intention therapies remotely. These therapies include: energy healing, intuitive healing, Spiritual healing, Healing Touch, etc.

Will Not Interfere or Replace *

I understand that receiving a healing session will not interfere or replace traditional medical or psychiatric care but can enhance other medical/psychiatric treatments. Therefore, clients under current medical or psychiatric care should not stop treatments or medication without advice of their physician/psychiatrist.

Does not Diagnose *

I understand that Shari does not diagnose or treat disease and is not a licensed physician or mental health practitioner

Not a Substitute *

I understand that these sessions are not a substitute for diagnosis or treatment from a qualified or licensed health practitioner for illnesses, injuries, or other medical conditions.

Communication *

I understand that communication will be predominantly via Doxy.me, a secure online meeting platform. However, some limited information may be sent via email and/or cell phone, which may not be secure. I take responsibility when using these communication channels to provide only that information I'm comfortable with sharing on these platforms.

Permission *

I give permission for Shari to leave or send me a message at the phone numbers and email addresses that I provide, as well as via Doxy.me. Most information will be provided via Doxy.me, while limited information may be left for me via the provided email and phone number.

Confidential *

I understand that all information between practitioner and client is held strictly confidential. There are legal exceptions to this: a. The client authorizes a release of information with a signature. b. The client presents as a physical danger to self or others. c. Abuse and/or neglect are suspected. d. The client is under criminal investigation and a subpoena by a court of law has been issued for information on the client. In the case of #b or #c above, we are required by law to inform potential victims and legal authorities so that protective measures can be taken.

Responsible *

I understand that I am responsible for payment of all fees charged at the time of service to be paid either prior to or on the day of service. I agree to pay for all services rendered.

Cancellations *

I am expected to arrive on time on agreed upon appointment date and time. If I am 15 minutes or more tardy, then I will be charged for this time accordingly. Cancellations must be made at least 48 hours prior to appointment; otherwise, I will be responsible for full cost of session. Should there be an emergency, no charge will be made, however, proof of said emergency will be required to void payment requirement.

Reserves the Right *

I understand that Shari reserves the right to refuse any session without providing a reason and can cancel said session at any time. Any payment made prior to a session that is canceled by the practitioner will be refunded in full.

Behavior *

I understand that my relationship with my practitioner is entirely professional and so any behavior on my part that is not professional and can be deemed sexual or abusive will be reported to the authorities.