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Consent

This informed consent MUST BE on file before any Shamanic Healing and/or Spiritual Counseling/Guidance appointments can be fulfilled.
PRINTABLE PDF

Earth Walk Medicine Informed Client Consent for Shamanic Healing and/or Spiritual Counseling/Guidance
 
Name_______________________________________________________Phone___________________________________
 
Address________________________________________________________________Email_________________________
 
Emergency Contact___________________________________________Phone____________________________________
 
The shamanic healing techniques utilized are imposed to encourage overall wellness and should not replace any mode of existing or suggested traditional medical treatment you may have been prescribed. Shamanic Healing is considered as "Spiritual Healing" and is not a medical treatment. This is a mystical application and no remedies are prescribed. No guaranties of wellness are made.
 
Spiritual counseling is offered solely as a support system on an interfaith level for individuals experiencing challenges during life transitions. Meetings follow the essence of the mystical healing presented here. This is not a place for psychotherapy. Psychotherapy will be recommended for mental disorders or situations where intentions to harm oneself or others is present.
 
During your session I will drum or use my rattle, sing and/or dance. I work with Healing Spirits to bring their Healing Power into you. Incense smoke is used. I may or may not wear a Sacred Mask. I might touch you with stones or other healing objects. You will be touched anywhere from head to toe, as I will use “laying on of hands” techniques. Some work might be done in darkness. You will remain clothed at all times. (I will ask you to remove your shoes). All things used bring good healing medicine to you. (“healing medicine” is a Native American term meaning spiritual or mystical medicine)
 
Participation from you is encouraged for ultimate success such as reviewing lifestyle changes, meditation, spending time in nature, or other suggestions brought about during a mystical session. It takes time to integrate the experience of a shamanic healing, so be kind to your self and allow the benefits to unfold. Not all results are instantaneous.
 
I have read the above information and understand what to expect.
(initial here) ______

 
Please read and initial each line below:
1) I acknowledge there is no guarantee of improved health or cessation of illness or symptoms.
(Initial here) _____
 
2) I agree this is a mystical application that is not intended as a medical treatment. It is not intended to replace any medical treatment I may be undergoing.
(Initial here) ____
 
3) I agree this is neither a medical clinic nor a facility that offers any form of physical or pharmaceutical therapy.
(Initial here) _____
 
4) I agree this is not a psychological treatment facility that offers counseling for mental disorders. Any Spiritual Guidance imposed is recognized as such in accordance with normal ministerial guidelines for an ordained minister.
(Initial here) _____
 
5) I give permission to receive Shamanic Healing and/or Spiritual Guidance from Reverend Shaman Sandra Chestnutt.
(Initial here) _____
 
6) Healing Touch Professional Association, the insurance company, requires Earth Walk Medicine/aka Reverend Shaman Sandra Chestnutt, to have clients sign this informed consent which includes: “Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Earth Walk Medicine/aka Reverend Shaman Sandra Chestnutt from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).”
I further release Touchstone Inn or any other premises or locations where services may be rendered from any liability of personal damages as a result of receiving Shamanic Healing and/or Counseling/Guidance.
(Initial here) _____
 
Print Name _________________________________________________________________________________________
 
Signature ___________________________________________________ Date ____________________________
 
(If under 18)
Print Parent/Guardian Name_________________________________________________________________________
 
Parent/Guardian Signature __________________________________________Date ____________________________

 

Updated 7/31/2015