Client In-take Form & Consent Form

Date

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Name

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Last Name

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Birthday

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Emergency Contact

First Name

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Reason for visit:

What would you like to work on during the energy medicine sessions, when did the concerns begin and what have you done that has helped?

Professional Help:

Have you received professional help for your concerns?

Are you currently under the care of a physician?

Yes

If you clicked yes:

Please list reasons below:

Please list:

Any recent or prior injuries, surgeries, accidents, major traumatic events or medical treatments and approximate dates: (Put N/A if not applicable)

Do you have allergies?

Please list: (drugs, chemicals, foods, airborne allergies, etc.) (Put N/A if not applicable)

Are you on any medications? Or taking any supplements?

Please list all that apply: (Put N/A if not applicable)

How would your life be different if you did not have this challenge?

What would you like to gain from your energy medicine session?

Are you willing to do self-care? For example, specific movements, to reinforce the work we do.

Please read carefully:

I understand that the energy medicine sessions I receive are provided for the basic purpose of harmonizing my body’s energies. If I experience any pain or discomfort during a session, I will immediately inform my practitioner. I further understand that energy medicine should not be construed as a substitute for needed medical attention. Energy medicine practitioners do not diagnose, treat, or prescribe for medical conditions. Energy medicine brings about physical improvements by impacting the electromagnetic fields that regulate the body as well as by shifting the more subtle energies described in other cultures with terms such as chakras, meridians, and etheric fields.

I agree and consent to the above

ESSENTIAL ENERGY MEDICINE INFORMED CONSENT AND SERVICES DISCLOSURE STATEMENT

What is energy medicine? I am a certified Eden Energy Medicine Advanced Practitioner, EEM-AP. Energy Medicine is an approach that involves balancing and restoring your body’s natural energies for the purposes of increasing your vitality, strengthening your mental capacities, and optimizing your health. The form I use draws from Donna Eden and her book, Energy Medicine. The techniques you will be experiencing and learning trace back to ancient healing and spiritual traditions such as yoga, tai chi, and acupuncture. The form I use and teach is thoroughly modern and does not require adherence to any particular set of beliefs or practices. The core concept is that your personal well-being and effectiveness are directly related to the state of your body’s energies. Enhancing Your Body’s Energies You may have heard about subtle energy through terms such as the “life force,” “chi,” “meridians,” “chakras,” “biofields,” or “auras.” In many healing traditions, the “life force,” the animating power whose presence defines life and whose absence defines death, is understood as a form of subtle energy. Eastern cultures in particular have studied such energies for millennia and have successfully applied their understanding for enhancing both physical and emotional health. Systems designed to influence the body’s subtle energies include yoga, Reiki, acupuncture, acupressure, tai chi, therapeutic touch, and energy medicine, to name just a few. Many hospitals in the United States now include such methods to help with the healing of a variety of conditions. Energy Medicine Techniques The techniques I will be using and teaching you are based on the premise that by promoting balance and flow in the body’s electromagnetic and subtle energies, health and well-being are enhanced. The techniques may involve the use of certain postures or movements or touching, holding, pressing upon, tracing, or circling over specified areas of the skin. They move, balance, enhance, and restore the body’s energies. I may also employ a procedure called “energy testing” where I apply light pressure to your outstretched arm, sometimes while you or I touch another area of your body. This is a way of assessing how your energies are flowing through specific areas of your body and may help us identify the techniques that will be most beneficial for you. The methods we will be using lend themselves to highly individualized applications in the studio as well as to back-home self-care. What are the limitations of my energy medicine practice? Although Energy Medicine uses the term “medicine,” it does not imply that Energy Medicine practitioners are practicing medicine. Energy Medicine is a term used by many training programs that teach people how to assess and correct for energy imbalances in the body. Energy Medicine is not a substitute for the diagnosis and/or treatment of medical or mental health conditions by a licensed health care professional. If you have a disorder that has been diagnosed by a licensed medical or mental health professional or a condition that should be evaluated by a licensed health professional, my services should be used only in conjunction with your obtaining that care. I do not diagnose or treat medical or mental health disorders, nor am I trained or licensed to do so. Energy Medicine attempts to optimize the body’s overall health and vitality, but it is not to be used instead of appropriate care from a licensed professional. Besides the fact that Energy Medicine does not diagnose or treat illness, another difference between my services and visits to a medical doctor is that effective energy work requires your active involvement between sessions. Our sessions will establish energy patterns that optimize body, mind, and spirit. Reinforcing these new patterns through the practice of energy exercises at home will reinforce, maintain, and extend the benefits you receive in the sessions. Energy Medicine techniques bring disturbed energies back to a state of balance and harmony. These corrections will generally consist of various forms of light or deeper touch and of movement of my hands within your body’s energy field. If you are uncomfortable with being touched or with any of the procedures being used, please tell me immediately and I will instantly stop. While the methods I use and teach are gentle and considered non-invasive, it is possible that physical or emotional after-effects may occur after your energies have been stimulated and adjusted. In some instances, deeper pressure is used to move energies that may be blocked or congested in a particular area of the body, and this may cause some pain or discomfort. Dizziness, nausea, or anxiety are relatively unusual but not unheard of side-effects to energy work. If any procedure is uncomfortable or leads to discomfort, please tell me at once. I will instantly stop if you request me to do so and can often provide a technique to counter the discomfort. My Background and Training For over thirty-five years, I have been actively involved in natural wellness, beauty, dance and healing modalities, as both a practitioner and a teacher. I have a B.S in Business, Dance/Theatre from Skidmore College in New York. Certified from the Boca Raton Fitness Institute as a personal trainer/ teacher ’Aerobics Thru Dance”. Licensed Esthetician NC E84 for 30+years,, Licensed Massage Therapist NC LMBT 1745 for 20+ years, Certified Clinical Aromatherapy Practitioner, CCAP for 20+ years, Eden Energy Medicine Advanced Practitioner, EEM-AP, EM Faculty member, Teacher Level 1-Fundamentals, Level 2 - Certification Training, Level 3 - Professional Mastery Skills,and Introduction to Eden Energy Medicine Part A & Part B, Certified Touch For Health Practitioner, Usui Reiki Master and Nia Black Belt Instructor. I love using energy alchemy to blend many of these beneficial modalities in my practice, along with sound, breath and movement…as these are all forms of Energy Medicine. Billings and Payments Energy Medicine Sessions Charges: 60 minutes $120 90 minutes $180 120 minutes $240 Sessions range from 1-2 Hrs. Session Packages are available. For more specific information please contact me directly. I accept Cash, Personal Check, PayPal or Venmo. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24-hours' advance notice of cancellation. If you are late, we will still end on time and not run over into the next person's session. If you miss a session without canceling, or cancel with less than twenty-four hours' notice, you must pay for that session by the time of our next meeting unless we both agree that you were unable to attend due to circumstances beyond your control. Acknowledgement, Consent, and Release of Liability:

By clicking this box you knowingly and voluntarily consent to the services offered by Lindy Franciose. Your signature indicates that you have read the information in this document, understand it fully, have discussed any questions or matters of concern with me and/or others, and agree to abide by its terms during our professional relationship.