CLIENT RELEASE FORM

Disclosure Statement: 

As a Complementary & Alternative Health Care Practitioner, I am not a licensed physician and am not otherwise licenses certified, or registered by the state of California as a health care professional.  As I am not a licensed medical physician, I do not diagnose, treat, or prescribe remedies for the treatment of disease.  The services I perform, whether in person, or virtual are at all times restricted to alternative or complementary  to healing arts services license by the state and are intended for the maintenance of the best possible state of general well-being. I act in accordance with California Senate Bill SB-577, which requires that I make the following disclosures:

“(A) That he or she is not a licensed physician.

(B) That the treatment is alternative or complementary to healing arts services licensed by the state.

(C) That the services to be provided are not licensed by the state.

(D) The nature of the services to be provided.

(E) The theory of treatment upon which the services are based.

(F) His or her educational, training, experience, and other qualifications regarding the services to be provided.”

Energy work is not licensed and it is not considered to be Traditional Western medicine. Further, you understand the services I offer, and the use of Reiki, Guided Meditation, Sound Healing, Crystal Healing & Aromatherapy (herein, the “services”) are not intended to be a substitute for medical or psychological treatment and they do not replace the services of licensed health care professionals.  You agree and understand it is your responsibility to consult with your health care provider for any specific health care problems and needs. You further agree to assume all risks associated with the services I may provide to you.

By signing this document you, as a client, understand I am offering my services solely as a complementary and alternative health care practitioner and our relationship is not to be construed as medical treatment, psychotherapy, psychological counseling, or any type of therapy, nor is it a substitute for these services.

I, the client, assume sole responsibility for my own health and for the results of the services provided by Danielle Elese. I release and hold harmless Danielle Elese from all legal liability during my participation in the session, even if Danielle Elese or any of her assistants, employees, agents, or volunteers are negligent.  I further release and hold harmless the owners, lessors, and/or any other individuals or businesses where Danielle Elese may provide such services, even if such owners, lessors, and/or any other individuals or businesses, and/or their respective heirs, personal representatives, affiliates, directors, officers, managers, members, sponsors, organizers, employees, volunteers, legal representatives, owners, agents, successors and/or assigns, are negligent. All of the foregoing parties are referred to hereinafter as the “Released Parties.” All information received by me from Danielle Elese is accepted with full knowledge that any action taken by me as a result of the information received is my complete responsibility. 

I understand that Danielle Elese retains the right to discontinue services at any time, even during a session, without explanation. 

I understand that sessions are a safe space for all involved and that clients must maintain professionalism and respect for the practitioner, Danielle Elese, at all times. 

This waiver and release of liability agreement shall remain in effect for the duration of my participation in the activity, during the initial and all subsequent events of participation, and shall further survive the termination of services offered by Danielle Else.

I hereby WAIVE, RELEASE, DISCHARGE, and COVENANT NOT TO SUE the Released Parties for and from any and all claims, costs, including attorney’s fees, demands, causes of action, suits, injuries, damages of any kind whatsoever, sustained by me, which arise out of my participation in the services offered by Danielle Elese.

The undersigned expressly agrees that the foregoing agreement is governed by laws of the State of California and is intended to be as broad and inclusive as is permitted by California law and that in the event any portion of this agreement is determined to be invalid, illegal, or unenforceable for any reason, the balance of the agreement shall not be affected or impaired in any way and shall continue in full legal force and effect.

In the event, any ambiguity is found to exist in the interpretation of this agreement, or any of its provisions, the parties, and each of them, explicitly reject the application of any legal or equitable rule of interpretation which would lead to a construction either "for" or "against" a particular party based upon their status as the drafter of a specific term, language, or provision giving rise to such ambiguity. Accordingly, the Parties specifically reject the application of Cal. Civ. Code §1654 to this Agreement, as well as any other statute or common law principles of similar effect.

The Parties hereto agree to attempt to resolve any dispute arising out of or relating to this Agreement through friendly negotiations by or between or among the parties. If the matter is not resolved by negotiation, the parties agree to resolve the dispute by submitting the matter to mediation in accordance with any statutory rules of mediation.

Privacy Notice: No information about any client will ever be discussed or shared with any third party without verbal or written consent. 

By signing this document I agree I have read all of the above.

Recommendation for Preparation & Post Care

• It is best practice to abstain from drugs/alcohol 24 hours prior to your session. The consumption of these substances can cause dissonance in the body when receiving the treatment.

• In addition, it is recommended to abstain from drugs/alcohol after the session. You will leave the session relaxed and sensitive. Try not to schedule any physical activity or intense social gatherings after your session. Give yourself time and space to reflect as you integrate.

• I highly recommend listening to one of my Sacred Sound Meditations before your session at least once. These recordings can be accessed on Insight Timer or Youtube under Foxy Sage. This gets you attuned to my voice and rhythm, making it easier for you to drop deeper into your session.

• Please wear light-fitting clothing, and have a blanket, water, and possibly an eye mask nearby, if you feel that, will make you more comfortable.

  (Blanket & eye mask will be provided for in office one on one sessions)

• During Virtual Sessions, please be alone and in a safe environment that is free from outside distractions (e.g., phones, people, etc.)

COVID-19 LIABILITY WAIVER AND ACKNOWLEDGMENT FORM 

I acknowledge the contagious nature of the COVID-19 virus and its variants. I acknowledge that Danielle Elese of Foxy Sage adheres to the CDC recommendations. I further acknowledge that Foxy Sage has put in place preventative measures to reduce the spread of the COVID-19 virus and its variants, to the best of their abilities. I further acknowledge that no guarantee exists regarding whether or not I may contract COVID-19 or its variants. I acknowledge that I may increase my risk of exposure to COVID-19 by participating.

I attest that: I am not experiencing any symptoms of illness such as cough, shortness of breath, difficulty breathing, fever, chills, muscle pain, headache, sore throat, or new loss of taste or smell.  I have not traveled internationally within the last 14 days.  I have not traveled to a highly impacted area within the United States in the last 14 days. I do not believe I have been exposed to someone with a suspected and/or confirmed case of COVID-19. I have not been diagnosed with Coronavirus/COVID-19 by state or local public health authorities within the previous four (4) weeks.

I hereby release and agree to hold Danielle Elese of Foxy Sage, participants, and volunteers harmless from any against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19. I fully understand that this release discharges the aforementioned from any liability with respect to bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to my participation as described above. 

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation. This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

Privacy Notice: No information about any client will ever be discussed or shared with any third party without verbal or written consent.

Cancelation Policy:

I agree to give a minimum of 48 hours' notice for all cancellations or changes of scheduled appointments. I understand that missing a scheduled appointment without prior cancellation or with a cancellation of fewer than 48 hours will be charged to me at the current full rate. I understand and agree to pay you, Danielle Elese, 30% of our agreed-upon full rate for rescheduling after a canceled or missed appointment. 

 Payment Policy: 

I agree to pay you, Danielle Elese, in full for your services before the date of each session unless otherwise discussed.