Client Information Consent Form

Client Information Consent Form

Authentic You Belief Coaching
Full Name*

First NameLast Name
Email Address*
Example: xxx@xxx.com
Age*
Example: 23 Years
What is your gender?
This is used in the Body Code Sessions when checking Systems, Organs and Glands
Mobile Telephone Number

Country CodeArea CodePhone Number
Where did you hear about my services?
Email onlyWhatsApp or Text Message (Please provide Mobile Telephone number above)
Yes, with no side effectsYes and I experienced side effects (Processing symptoms or echoes of the emotions released)No
YesNoNot Applicable
YesNo
Any health related notes I should be made aware of?

If you have booked this service, please confirm the names of the connections to be investigated:

Rows	1 x 60 mins clearing on up to a maximum of 4 people/pets who are connected to you. I will identify any energetic blocks you have related to other individuals or pets specified.
First Name of Person / Pet 1
First Name of Person / Pet 2
First Name of Person / Pet 3
First Name of Person / Pet 4

If you have booked this service please confirm the topic to be investigated:

Rows Topic for me to investigate:

Topic

Rows	Topic for me to investigate:
Topic

If you have booked this service please confirm the topic to be investigated:

Rows Topic for me to investigate:

Topic

Rows	Topic for me to investigate:
Topic

If you have booked this service please confirm the names of the connections to be investigated:

Rows	1 x 60 mins clearing on up to a maximum of 4 people/pets who are connected to you. I will identify any energetic blocks you have related to other individuals or pets specified.
First Name of Person / Pet 1
First Name of Person / Pet 2
First Name of Person / Pet 3
First Name of Person / Pet 4

Pets Name and Age

NameAge
Rows Topic for me to investigate:

Topic

Rows	Topic for me to investigate:
Topic

If you have booked this service please confirm the following information:

Rows	Chart Input information
Birth Year (Example 1956)
Birth Month (Example Sept)
Birth Day (Example 05th)
Birth Hour/Minute (Example 12.50 am)
Birth City (Example Southampton)
Birth County (Example Hampshire)

If the subconscious mind is resistant, you are sensitive to energy clearing or you want to minimise the impact of any discomfort that could result from processing echoes, the service may need to be performed over a period of weeks.

Rows	9am - 12am UK
Monday
Tuesday
Thursday
Friday
Saturday

Please upload any relevant Photographs to aid the proxy connection:*

Cancelof
Scope of Practice
➡️ I acknowledge that Hayley at Authentic You Belief Coaching uses the Emotion Code, Body Code, and Belief Code holistic therapy methods developed by Dr. Bradley Nelson at Discover Healing. These energy healing methods are often used as a complement to conventional medical care, supporting harmony, balance, and the body’s natural ability to heal.

Medical & Therapeutic Boundaries
➡️ I understand that releasing trapped emotions or correcting energetic imbalances through these methods is not a substitute for medical or mental health care.

➡️ I accept that any information provided by Hayley at Authentic You Belief Coaching is not medical advice and should not be used for diagnosis or treatment. These methods are not a replacement for professional psychotherapeutic sessions in the treatment of mental health issues or disorders.

➡️ I recognise that Hayley at Authentic You Belief Coaching does not make any claims regarding healing or recovery from any illness or mental health issue, nor regarding the prevention of any future illness or mental health issue.

➡️ I agree that if I have health concerns, I am encouraged to seek advice from an appropriate medical practitioner before making decisions about my health.

Processing & Outcomes
➡️ I acknowledge that in some sessions (approximately 1 in 5), the release of trapped emotions or other energies may result in “processing,” where an echo of the emotion released may manifest as temporary physical or emotional discomfort. I understand this appears to be a normal part of regaining energetic balance. (See FAQ Tab on the website for more information.)

➡️ I accept that no guarantees are made regarding any particular outcome of sessions, whether relating to my physical health, mental health, or otherwise.

Confidentiality
➡️ I understand that sessions are confidential and that records are kept private, except where disclosure is required by law.

Permission
➡️ I give permission for Hayley at Authentic You Belief Coaching to connect with me, my child, or my pet energetically during sessions in order to perform subconscious healing or rewiring.

➡️ I acknowledge that I am advised to be self-informed about this work by visiting Dr. Bradley Nelson’s website: https://discoverhealing.com/

Refund Policy
➡️ I understand that due to the nature of this service, refunds are not available once sessions have been completed.
Yes, I provide my consent for the duration of the Service period
I do NOT wish to be added to the Authentic You Belief Coaching mailing listI wish to be added to the Authentic You Belief Coaching mailing list to keep me updated on new services.
Yes, I provide my consent
Should be Empty: