Client Consent Form
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Before scheduling our Initial Awakening Session, please read and submit the consent form below. Thank you and I look forward to working with you!
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| First Name:* |
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| Last Name:* |
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| Address Street 1:* |
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| Address Street 2: |
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| City:* |
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| Zip Code:* |
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| State: |
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| Preferred Contact Phone:* |
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| Alternate Contact Phone:* |
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| E-mail:* |
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| Please choose your preferred days for your session: |
Monday Tuesday Wednesday Thursday Friday
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| Please choose your preferred time of day for your session: |
9:00 a.m. - 12:00 p.m. 12:00 p.m. - 3:00 p.m. 3:00 p.m. - 6:00 p.m.
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| Referred By: |
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I, (enter full name)*, acknowledge that I have voluntarily agreed to participate in a session, or multiple sessions, with Alanna Arthur of Awakening The Divine Within, and therefore enter into the following Agreement with Alanna Arthur of Awakening The Divine Within.
I acknowledge that Alanna Arthur of Awakening The Divine Within is not a Psychologist, Psychotherapist, Psychiatrist, Licensed Mental Health Counselor or Medical Doctor. I understand that Alanna does not diagnose problems, prescribe solutions, dispense medical advice, heal or cure anyone or anything. I am aware that my participation in any session with Alanna is not a substitute for psychiatric treatment, psychotherapy, therapeutic counseling or any other form of professional therapy or medical care. I also understand that if any information is given during my session that may pertain to medical and/or mental health, this is not a declaration of fact being made by Alanna Arthur of Awakening The Divine Within, but only an intuitive impression Alanna is receiving at that time. I understand that it is up to me to interpret any intuitive, or other information, which Alanna may share in a session, in my own way and only take the action steps that I feel are right for me. I agree to take sole personal responsibility for any actions I take or choices I make in or outside of a session. I understand that Alanna Arthur, of Awakening The Divine Within disclaims any liability for any choices I make at any time. I accept complete responsibility for my own physical, psychological, mental, emotional and spiritual well-being. I acknowledge that it is my responsibility to ascertain my own need for professional counseling or medical care and to seek such professional help, if needed. I acknowledge that the information received in a session is for informational, educational, and entertainment purposes only and is not intended to replace mainstream professional care or advice from other qualified professionals.
I acknowledge and understand that any information provided or statements made during this session shall be considered confidential and shall not be disclosed except as required by law.
I agree to be on time, present, ready, and prepared for all sessions and if for any reason I am not, I understand that this will cut into the allotted time. I understand that there is a minimum 24 hour (1 business day) appointment cancellation policy. I am responsible for the cost of the session if an appointment is missed or cancellation is made without giving a minimum 24 hour notice. If I need to reschedule a session, I will notify Alanna at least 24 hours in advance and a new session will be scheduled, pending Alanna’s availability for the week.
I acknowledge and understand that payment is required at the time of scheduling a session. I understand that if for some reason the payment is not received a minimum of 24 hours in advance of the session, the session will be rescheduled until after the full payment has been received. Fees may change, if they do, any price increases or decreases will only go into effect after the completion of any pre-paid package of sessions. Sessions purchased in packages are designed to be used as weekly or every other week sessions. I understand that there are no refunds.
I have carefully read this Agreement and fully understand its contents, terms and significance and understand the legal consequences of signing this Agreement. I am aware that this Agreement contains a release of liability and a contract between myself and Alanna Arthur of Awakening The Divine Within and I sign this Agreement of my own free will.
I acknowledge that by typing in my full name and today's date below, this serves as an Electronic Signature and in doing so I am confirming that I have read, understand, and agree to ALL of the above stated information.
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| Full Name (ElectronicSignature):* |
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| Today's Date:* |
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If you would like a copy of this consent form for your records, please print this page before pressing the "submit" button below. |
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