NOTE :
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  Informed Consent

WE CONSIDER ENTERING INTO HEALING ALLIANCE WITH EACH OTHER A SACRED TRUST THAT BINDS BOTH PARTIES. RESPONSIBILITY FOR YOUR LIFE IS ALWAYS WITH YOU, EVEN WHILE WE ARE INTIMATELY EXPLORING IT TOGETHER. EVERY THING WE DO WILL BE WITH YOUR FULL AWARENESS, YOUR APPROVAL AND YOUR SENSE OF FEELING SAFE AND RIGHT ABOUT IT. YOU ARE INVITED AND ENCOURAGED AT ALL TIMES TO DISCUSS OPENLY AND FREELY WITH THE HEALER ANY QUESTION OR CONCERN YOU MIGHT HAVE ABOUT THE PROCESS. YOU RETAIN THE RIGHT TO TERMINATE COUNSELING AT ANY POINT.

CONFIDENTIALITY: All information concerning you, even the fact that you choose King's Oracle services, will not be shared with other persons without your permission. However, as professionals, it is our responsibility to seek supervision with other consolers or healers. Through this you consent and give your permission for us to share aspects of our time together with appropriate consultants, who are likewise sworn to confidentiality. Also, if there is reason for us to believe that you are likely to do physical harm to yourself or another person, then it is the healer's responsibility to notify the appropriate authorities.

CANCELED APPOINTMENTS: Once a specific meeting time is agreed upon, you are responsible for it until we choose to terminate. Cancellations are not workable, since that is your slot and filling it with another appointment would make it unavailable to you. It is possible to negotiate alternate times when circumstances change.

OTHER SERVICES: We are only one option on the road to wellness. We will assist you in seeking other professional help as the need may be. It is desirable that you check out other practitioners and seek medical intervention when indicated. Referrals could be appropriate before, during or after our time together.

CONSENT: I have read the preceding and I choose to enter into a healing relationship with King's Oracle healer. I understand that my consenting to this form does not commit me to a binding contract, but indicates my willingness and an informed consent to begin a healing process with King's Oracle.

* YES ... I GIVE MY CONSENT    Please Initial *

Please fill out this following information form. Required fields are marked with an asterisk(*). Once the form has been completed, click the "Continue" button at the bottom of the page to go on to the Service Order page.

   
Date (mm/dd/yy)
 
First Name *
Last Name *
Address 1
Address 2
City
State (xx)
Zip - (xxxxx xxxx)
 
Home Phone * (xxx) (xxx-xxxx)
Work Phone (xxx) (xxx-xxxx)
 
e-Mail *
   
  Client Intake Form
   
   
Birth
Height
Weight
Relationship Status
Children / Ages
Occupation
 
Physician
Physician Phone (xxx) (xxx-xxxx)
 
Psychotherapist
Providers may be contacted by healer?
Yes   Initials    No    
 
Reason for Initiating Contact
 
Date of Onset

   
Previous Treatment
 
Medications currently taken
 
Non prescription drugs (vitamins, herbs, over the counter
 
 
Do you use / how much: Tobacco
Alcohol
Caffeine
Sugar
 
Diet
Exercise
 
Vision
Smell
Hearing
Taste
 
Accidents with dates
Surgeries with dates
 
What are your goals / expectations?
 
Short Term
 
Long Term