Client Consent Form
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  • Format: (000) 000-0000.
  • Braveheart Wellness

    Hi, I am Andrea Gray a certified Yoga and Assisted Athletic Stretch & Mobility therapist with several years of experience specializing in various ancient techniques such as Yoga, Thai Therapy, Gua Sha and assisted stretch. I value my relationships with each client and believe that such relationships are a beacon in the healing process.

    I hereby consent to the stretch therapy and other massage procedures as of hydrotherapy, stretching services provided on me.

    I acknowledge that I have the right to discuss the nature of treatment, treatment procedures and my health condition with the therapist.

    I understand that therapeutic stretch therapy does not diagnose and heal illness, disease, any physical or mental disorder. Stretch therapy is not a substitute for medical examination. I understand that thistreatment is designed to address the care and prevention of myofascial pain and dysfunction.

    I understand that there can be risks to treatment, including but not limited to, tenderness, bruising, light headedness or dizziness which I do not expect all risks and complications to be explained before the treatment and I wish to rely on the judgement of my stretch therapist regarding any risk management.

    Also, at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic therapist.

    I understand that I will be clothes at all times and the areas undraped will be secure to insure there is no indecent exposure.

    I will also have the privacy to undress/dressed and the therapist will knock and wait for my reply upon entering.

    By my electronic signature below, I agree to the therapy policy and client agreement above.

  • Acknowledgement

    I have reviewed this Professional Counseling Informed Consent Agreement. 

    I accept this agreement and consent to counseling.

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