Who Knew Healing New Animal Intake Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Accept Text?*

YesNo

Email address*

example@example.com

Reason for session:*

How did you hear about us?*

Would you like to be added to my email list? I will not overload you with emails I promise!

YesNo

I state that I will respect boundaries and all communication will be during office hours. I understand that office hours are 9am-6pm (MST) Monday through Friday.*

I understand an agree

If you want your session to be recorded, please use a computer. Recording is not supported on phones or other mobile devices. The recording will be saved directly to your computer.*

I understand an agree

There is a $50 fee for cancellations or no shows with less than 24 hours' notice. Appointment hours are 10am-5pm (MST) M-F. Office hours are 9am-6pm (MST)M-F.*

I understand and agree

I understand Alicia Sweezer is not a medical doctor and does not practice medicine. She does not diagnose, heal, cure, prevent, prescribe, or perform medical treatments, prescribe substances, treat disease, or interfere with the treatment of a license medical professional. She assists people in correcting energetic imbalances that enables the body to release its innate healing ability. When the energy of the body is balanced and moving correctly, the body’s own energy heals itself. All the healing is self-healing. I understand energy work is not a substitute for any medical diagnosis or treatment. I understand it is recommended that I see a licensed health care professional for any physical or psychological issues I may have. I understand energy work can complement any health care I may be receiving. I understand Alicia Sweezer doesn’t make any promises, warranties, or guarantees about the results of her work. I give my consent for Alicia Sweezer to touch my body for the benefit of releasing that which limits me in areas of my life I want to change. I understand this is NOT therapy. I have had the opportunity to ask Alicia Sweezer questions re: this process and feel comfortable in the information I have received. Except in the case of gross negligence, I or my representative(s) agree to full release and hold harmless Alicia Sweezer from and against any and all claims of liability of whatsoever kind of nature arising out of or in connection with my session(s), including Covid.*

I agree

Date*

Date

Signature*

Who Knew Healing LLC