• Energy Regulation Intake Form

  • Format: (000) 000-0000.
  • Have you been experiencing any of the following: (Check those that apply)

  • Consent

    Upon consenting, I acknowledge that I can not be under the influence of any illicit substances or plant medicine during a session. I confirm that I am of an appropriate level of health, and will inform the practitioner before each session of any relevant and or essential health information.

     

    Release of Liability 

    By participating in any service provided by Ashley Feltz, you acknowledge that:

    These are complementary wellness modalities and are not a substitute for medical diagnosis, treatment, or professional healthcare advice.

    The practitioner does not diagnose conditions, prescribe medications, or perform medical treatment.

    Results vary from person to person.

    "By signing below, I agree to release Ashley Feltz from any and all liability, claims, or demands that may arise from my participation in any services offered. 

    I acknowledge that I am participating voluntarily and assume full responsibility for any physical, emotional, or mental effects that may result.

    If I have any medical concerns or are under the care of a physician, I confirm that I have consulted with them prior to beginning these sessions, or that I take full responsibility for proceeding without such consultation".

  • Should be Empty: