Energy Healing Intake and Waiver Name * First Name Last Name Email * Your Occupation What type of session would you like to book? * 30-Minute ($45) 45-Minute ($60) 60-Minute ($75) How would you like to receive your session? * Zoom (camera on) Distant (no technology) Please list some preferred dates/times for your session. * What is your preferred method of payment? * Paypal Venmo Credit Card Other Have you experienced an energy healing/energy work session before? If so, which kind? * Yes - Reiki Yes - Pranic Healing Yes - Other Energy Work No - this will be my first time Do you have any of the following medical devices? (This question is asked because it will reflect how the healing is facilitated.) Hearing Aid Pacemaker Port None Other Please describe any particular area(s) of the body where you are experiencing tension, stiffness, pain or other discomfort: Please list any particular emotions you may be experiencing that you'd like to release during this session: Please list any particular goals or areas of preferred concentration for this Energy Healing session: Is there anything else about your health history that you think would be useful for your Energy Healing practitioner to know to plan a safe and effective Energy Healing session for you? How did you hear about Rose Gold Energy / Rachele Rose? * I agree to all terms listed in the Consent to Energy Healing & Release from Liability. Consent is required to receive session. * Consent to Energy Healing & Release from Liability By registering for Energy Healing sessions with Rachele Rose/Rose Gold Energy, I the Client, understand that the energy healing sessions may involve a natural method of energy balancing for the purpose of pain management, stress reduction, and relaxation. I understand very clearly that these treatments are not intended as a substitute for medical or psychological care. I understand that at any time if I feel discomfort, I may ask for the session to be stopped (session can be resumed after problem is addressed). I understand that Rachele Rose/Rose Gold Energy does not diagnose conditions, nor does she prescribe medicines, nor interfere with the treatment of a licensed medical professional. I understand that it is recommended that I seek a licensed health care professional for any physical or psychological ailment I have. I agree to take full responsibility for my own safety and well-being; and release Rachele Rose from any liability associated with Energy Healing sessions. I hereby release Rachele Rose and/or Rose Gold Energy from any and all liability, negligence, or other claims, arising from, or in any way connected with my participation in Energy Healing sessions. Agreeing to these terms further acknowledges that I shall not now, or at any time in the future, bring any legal action against Rachele Rose or Rose Gold Energy. My registration is binding to this liability waiver from this day forth. Disclaimer: Energy Healings are not to be taken as professional medical advice. Yes No
