Client Intake & Waiver Form for Emma

Therapeutic Sessions with

Emma Mcwilliam | Empowered Healing Hub
Who is the appointment for?*

MyselfA person I care for
Client's Name (The person receiving treatment)

First NameLast Name
Client's Date of Birth

MonthDayYear
Date
What appointment type have you booked?

Stress & Trauma ReleaseBowen/CST Nervous System SessionHypnotic BreathworkExpress Guidance Therapy Session
Client Information

If this is your first time seeing Emma or you have new information to add, tell us a bit about you before your session so we can get straight into assisting you when your appointment commences.
Tell me about yourself & the dynamics going on for you at the moment.
What brings you to seek treatment? What are the struggles in your life or re-occuring issues you face?
In your opinion, what’s preventing you from overcoming the hurdles or creating roadblocks?
What is the ideal scenario post therapy? What changes do you hope to see?
Have you had mental health diagnoses, therapy, coaching or notable treatment before? List the practices, diagnoses, protocols or professional services that you have participated in previously that you feel is important for me to know.
Do you take any medications relating to chronic physical symptoms, stress induced symptoms or that might influence you in this session or your treatment outcomes? Please disclose relevant medications and the illness they accomodate here.
Do you have symptoms relating to any of the following?

AllergiesDiabetesSkin IrritationHeart ProblemsVaricose VeinsCancerHigh Blood PressureLow Blood PressurePoor CirculationBreathing IssuesPregnancyEye IssuesHypermobilityIBS/Gut IssuesOther
Legal Waiver & Release For Clients

Emma McWilliam | Empowered Healing Hub

6 Forest Avenue, Newhaven

Victoria, Australia

ABN: 17707944060

I am here to inspire my own personal transformation and change. I take full responsibility for my life and my decisions before, during and after my energy healing session/workshop.

I understand that sessions provided by this therapist are complementary healing that in no way forms a substitute for medical or psychiatric interventions. I also understand that the therapist may make suggestions for self-care as well as appropriate referrals which I can choose to follow through at my own will.

I understand that all clinical information provided and records of healing treatments etc. will be kept confidential and will not be released without my written consent and that it is not the responsibility of the therapist to seek medical intervention on my behalf. I have carefully read this agreement and fully understand its content. I am aware that this is a waiver and a release of potential liability against Emma Mcwilliam of Empowered Healing Hub and a contract between the above noted parties and myself.

I acknowledge that open communication is promoted between me and my practitioner to enhance mutual understanding and acceptance of the energy work provided during the treatment setting.

I understand that each session is different and is based on what the client needs. I understand that majority of most sessions will be done lying down and that gentle touch may be used where necessary to assist in shifting energy. I understand that I can tell my practitioner to stop at any time should I feel uncomfortable in any part of the session.

I have been informed that energy medicine is a generally safe method of treatment, but that shifts in energy occur and may create some physical, emotional, or spiritual side effects which may include physical tingling, feeling lighter energetically, mild fatigue, nausea, muscle soreness, headache, thirst, changes in relationships, shifts of perception, etc. I understand that results are not guaranteed. I hold my practitioner harmless from any possible effects that may cause temporary physical or emotional discomfort and agree to take full responsibility for my self-care and personal development.

I have carefully read this agreement and fully understand its content. I am aware that this is a waiver and release of potential liability and a contract between the above noted parties and myself. I understand that this contract is binding and acknowledge that I am signing this of my own free will.
Legal Waiver & Release For Guardians

Emma McWilliam | Empowered Healing Hub

6 Forest Avenue, Newhaven

Victoria, Australia

ABN: 17707944060

I am here to support the transformation and change of someone I am a legal guardian for. I take full legal responsibility for their life and their decisions before, during and after their energy healing session/workshop.

I understand that sessions provided by this therapist are complementary healing that in no way forms a substitute for medical or psychiatric interventions. I also understand that the therapist may make suggestions for self-care as well as appropriate referrals which I can choose to follow through at my own will with the client's best interests in mind.

I understand that all clinical information provided and records of healing treatments etc. will be kept confidential and will not be released without my written consent and that it is not the responsibility of the practitioner to seek medical intervention on my behalf or on behalf of the client recieving the treatment that is in my care. I have carefully read this agreement and fully understand its content. I am aware that this is a waiver and a release of potential liability against Emma Mcwilliam of Empowered Healing Hub and a contract between the above noted parties and myself.

I acknowledge that open communication is promoted between me, the client in my care and the practitioner to enhance mutual understanding and acceptance of the services provided during the treatment setting. I understand that in certain circumstances the client receiving the treatment may request that some information be kept private during the sessions or request that they be alone in the treatment room during the booking. I consent to the client in my care being alone to receive treatment if the client requests this to be the case or engaging in communication directly with the practitioner if they wish to do so.

I understand that each session is different and is based on what the client needs whilst under practitioner care. I understand that majority of most sessions will be done lying down and that gentle supportive touch may be offered where necessary to assist in shifting energy. I understand that I, or the client in my care, can tell the practitioner to stop at any time should I, or the client in my care, feel uncomfortable in any part of the session.

I have been informed that energy medicine is a generally safe method of treatment, but that shifts in energy occur and may create some physical, emotional, or spiritual side effects which may include physical tingling, feeling lighter energetically, mild fatigue, nausea, muscle soreness, headache, thirst, changes in relationships, shifts of perception, etc. I understand that results are not guaranteed. I hold my practitioner harmless from any possible effects that may cause temporary physical or emotional discomfort and agree to take full responsibility for the self-care and personal development of the client in my care.

I have carefully read this agreement and fully understand its content. I am aware that this is a waiver and release of potential liability and a contract between the above noted parties and myself. I understand that this contract is binding and acknowledge that I am signing this of my own free will.
Bowen & Craniosacral Therapy

Legal Waiver & Release

Emma McWilliam

6 Forest Avenue, Newhaven

Victoria, Australia

ABN: 17707944060

I understand that Empowered Bowen & Craniosacral Therapy is for the purpose of pain relief, stress reduction, relief from muscular tension and spasm, improvement of circulation, energy, alignment and lymphatic flow.

In a strictly medical sense, both Bowen & Craniosacral Therapy do not cure anything. They allow the body to heal itself the way it is designed to.
I understand the Bowen & Craniosacral Therapy Practitioner doesn’t diagnose illness, disease, or any physical or mental disorder. The practitioner does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulation.

It has been made clear that the Bowen & Craniosacral Therapy Practitioner is not a substitute for medical examination or diagnosis and that it is recommended that I see a medical doctor for any physical ailment that I may have.

I understand that services offered today, and in the future, are not a substitute for medical care and that any information provided by the therapist is for education and relaxation purposes only, and is not diagnostically prescriptive in nature.

I have stated all of my known medical conditions on the intake form or updated them to my current circumstances.

I realize it is solely my responsibility to keep the Bowen & Cransiosacral Therapist updated on any changes in my health and I understand that Emma Mcwilliam at Empowered Healing Hub shall not be liable should I fail to do so.

I agree to actively participate, as much as possible in my own healing and health maintenance.
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Phone Number*

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Date*

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Therapeutic Sessions with

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