New Client Onboarding Form: Kellie Rose

Name

First NameLast Name

Phone Number

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

example@example.com

Are you left or right handed? This makes a difference to the direction I move through your energy field it the closing sequence.

How did you come to find me?

Emergency Contact:

First NameLast Name

Emergency Contact Phone Number

Their relationship to you

Staying in Touch: I'm happy to receive occasional emails with updates, tips and offers. You can unsubscribe at any time. Your details will never be shared.

What is the main thing you'd like to work on?

What would life look like without this problem? What do you want instead of how things are today? If you could wave a magic wand, what would you like to gain from our time together? (It's important to include what you WOULD like, not what you would not like)

Do you know a place (real or imaginary) where you feel here you feel calm and at ease? If so, could you please describe it briefly.

Anything else you'd like me to know.

In my daily life I would consider myself to be...

In my daily life, when it comes to emotions, I consider myself to be...

In my daily life, when it comes to my thoughts, I consider myself to have...

In my daily life, when it comes to my energy levels, I consider myself to have...

In my daily life, when something I consider disastrous happens, I am likely to believe

In my daily life, I experience my body as...

Before completing this section, please take a moment to read the Biofield Tuning Cautions & Guidance document. It covers specific circumstances - including medications, metal implants, and certain health conditions - that may affect how we work together.

Please mark all that apply and provide any additional health information below relevant to you at this time that you'd like me to know:

If you have ticked any boxes, please provide further details here

Is there anything else I should be aware of to help you feel comfortable in our sessions?

(Triggers, previous experiences, or preferences it would help me to know)

Each body is unique and each session experience is different. Most people report feeling lighter, clearer, calmer and more self-aware. On occasion, some people experience a detox response in the days following a session - this is normal and passes.

Please take a moment to read about post-session care

Post Session Care

I’m happy for my session to be audio-recorded so I can re-listen and integrate my experience. Recordings also help my practitioner keep more comprehensive session notes and stay present during the session and reflect accurately on what arises to support my ongoing progress. All recordings are kept private and securely stored, and will never be shared with anyone except yourself without permission

I have provided my information to the best of my knowledge, including pertinent health information. (For Parent or Guardian if client is under 18)

Waiver Form

Liability

I, (The Client) ___, hereby release Kellie Rose from any liability or claims that could be made against (her) concerning my mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form.

Scope of Practice

I understand that Kellie Rose is not a licensed physician, psychologist, or medical practitioner of any kind, and that the work she offers should not be considered a replacement for the advice or services of a psychiatrist, psychologist, psychotherapist, or doctor. The sessions I receive are complementary in nature and are not a substitute for professional medical or psychological care.

Participation

I give Kellie Rose full permission to conduct sessions with me (or my child, if the child is under 16) using the methods she has trained in and considers appropriate to my situation. I understand that my own willingness and engagement play an important role in my overall experience and outcomes.
Touch Consent
Where sessions are conducted in person, I give permission for Kellie Rose to use light touch and the application of weighted forks on my body where appropriate. I understand that I may withdraw this permission verbally at any point before or during a session.
Remote Sessions
I understand that sessions may be conducted remotely via video call and that this agreement covers both in-person and remote sessions equally. I understand that the effectiveness of remote sessions is not diminished by physical distance.

Guarantee

I understand that Kellie Rose cannot and does not guarantee specific results. My experience depends on many factors outside her control, including my own readiness and engagement with the process.

Confidentiality

I understand that Kellie Rose will keep all information shared in sessions strictly confidential, with the following exceptions: if it has been determined that a child or elder is at risk of or is currently being abused; if I am in imminent danger to myself or others; or if a subpoena of records has been requested. Kellie Rose may discuss aspects of my case with professional colleagues for supervision purposes, with my full name and identity kept confidential at all times unless I have given permission otherwise.

Cancellation
I understand that I am free to cancel my appointment at any time, and that this must be done by email, if I cancel after 24 hours before my appointment, the full appointment fee is payable.

Signature of Client (or Parent/Guardian if client is under 16)

By signing I confirm that I have read and accepted the above conditions and that the information provided is true and correct.

Date

Client Intake Form

About You

Emergency Contact (Must be over the age of 21)

Where you're starting from

How You're Feeling Right Now

Health & Cautions

Consent and Agreement