Kabir Center for Health - PSYCH-K® Intake Form

Integrative Subconscious Change | PSYCH-K® Intake Form

Kabir Center For Health
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
How were you referred to us?*
What are your primary goals? (Please read the "Questions to Think about before your Session" on our website to properly guide you through this step)*

Our PSYCH-K Facilitator incorporates Human Design into your sessions. Human Design gives your unique energetic blueprint, providing invaluable insight to realigning and reconnecting with the being you were born (designed) to be. This road map gives insight into how your energy flows, how your brain and body function, how to best make decisions, what your unique gifts are and how to share them with the world, how to approach work, rest, life in an aligned manner. Human Design goes beyond personality and is a holistic guide to living your authentic truth.

Please complete the information below:
Date of Birth*

MonthDayYear
Date
Exact Time of Birth*

Hour Minutes

AM/PM Option
Please note: An exact time of birth is required and can typically be found on your birth certificate.
Location of Birth (City/State)*
DISCLAIMER

I understand that the PSYCH-K process is strictly limited to the modification of beliefs and is not designed to diagnose medical problems, nor is it a replacement for medical attention or professional mental health care. I also understand that, while the PSYCH-K® process can help modify personal limiting beliefs and perceptions around health, it does not heal or cure conditions.

I understand that I have not been given any guarantees or promises regarding the outcome of my PSYCH-K® session and that, while Kara Tiede-Kabir can help me identify and change subconscious beliefs, the outcome and results may be dependant on my action steps and I understand that it may take more than one session to transform my current experience fully.

I also understand that sessions are non-refundable, non-transferable, and cancellations/reschedules of appointments made less than 24 hours notice may result in a cancellation fee.
I've read and understand*

PHOTO / VIDEO RELEASE
I hereby authorize Kabir Center for Health and/or other brands owned by Kabir Center for Health, to use my thoughts, comments, experiences, testimonial, treatment, or story for use in image, video, or still. I understand that my image may be edited, copied, exhibited, published or presented in presentation under any legal condition, including but not limited to: marketing, illustration, medical, scientific publication, social media, and web content. In addition, I understand that this material may be used within an unrestricted geographic area.

I agree that there will be no direct payment, royalties or other compensation offered to me by the company arising or related to the use of my image or recording.

I understand that I may revoke this photo/video release at any time by notifying Kabir Center for Health in writing within 48 hours of capture. The revocation will not affect any actions taken before the receipt of this written notification. Images/videos will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

By signing this release, I acknowledge that I have completely read and fully understand the above consent for procedure and image release and agree to be bound thereby. I hereby release any claims against any person or company utilizing this material in compliance with the aforementioned restrictions.
Signature*

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Child's Name (if applies)

First NameLast Name
Guardian Signature (if applies)

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Integrative Subconscious Change | PSYCH-K® Intake Form

PHOTO / VIDEO RELEASE