Client Profile Form

Greeting!! Please fill out our client profile form. We want all our clients to properly be prepared for their sessions and the client profile form will remains current in our system.

This form allows for things to remain sychronized to provide the highest level of care and understanding of how we can help you.

If you are an existing client, you will complete this form ahead of time to have a record of the progress happening in between your sessions. If you are a new client, you will complete this form to create your client profile.

Thank you! 

Your experiences during our sessions are confidential, and you have a right to view your client profile records upon written request. You can send an emailed request to theholisticwomb@gmail.com or give our us a call at 773-819-0894 for additional help.

Confidentiality is subject to the following exceptions:

• You instruct me to release information to other health care practitioners and/or other individuals, in writing.
• I am subpoenaed or otherwise legally obligated or reasonably allowed to do so (including circumstances where there is clear and imminent danger to yourself or another person).
• Your confidential client profile is kept in a secure location and is retained for 5 years after you end services, after which time all information will be destroyed in a proper manner.
• Your confidentiality is always subject to the usual exclusions dictated by state and federal laws and regulations.

Ahava Kherut Bey and Timothy Ruther provides personal empowerment services and biopsychosocial healing sessions to support natural, non-invasive, and non-toxic healing experiences and coaching. Ahava and Timothy provides a description of her certifications and education here that have contributed to her scope of care.

I understand that Ahava Kherut Bey or Timothy Ruther is not a licensed physician or coach, as her scope of care, at present, is unregulated and therefore, her services are not licensed by the state of Illinois. I understand it is my responsibility to maintain a relationship for myself with a medical doctor, mental health professional, or any other essential specialized health professional, if I so desire. I further understand that Ahave Kherut Bey or Timothy Ruther is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies. I also understand that the statements and services offered have not been evaluated by the US Food and Drug Administration. I understand that the recommendation of herbal care, teas and supplement are not to diagnose illness.

I understand that methods of treatment may include, but are not limited to: Vaginal Steaming, Chinese and Western herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the staff of any unanticipated or unpleasant effects associated with the consumption of any herbs, teas, or  supplements that Are recommended.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant) that have been recommended are traditionally considered safe in the practice of Chinese Herbs and Western Herbs although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomach ache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a staff member who is caring for me if I am or become pregnant.
I do not expect the staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the staff to exercise judgment during the course of treatment which the staff thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed.

I hereby release, waive, acquit and forever discharge The Holistic Womb, Zion Wellness Center, Ahava Kherut Bey Timothy Ruther an any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by Ahava Kherut Bey or Timothy Ruther as a result of the recommendations given or otherwise resulting from any booked sessions. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.

 

• PLEASE DO NOT 

Participate in this treatment; If you are allergic to any plants or herbs including mugworth, motherworth, oregano, yarrow, lemongrass or rosemary. If you have a gastro-intestinal flu, vomiting or have diarrhea. Or any herbs that has you have been allergic to. Please provide Ahava or Timothy of any allergic to any herbs, plants or supplements. 

Other herbs or any substances put into the original blend by client, is hereby responsible and is used at ther own risk and do not hold Ahava Bey, Timothy Ruther, The Holistic Womb, Zion Wellness Center, liable for any negligence of any kind. 

On prescription medication, including beta blockers, diuretics or barbiturates, can affect your heart rate or interfere with your body’s natural sweating system. Make sure to check with your doctor about side effects of your medication 

Heart disease, hypertension, hypotension, hyperthyroidism, hemophilia, diabetes, cancer, Parkinson’s, systemic lupus erythematous, or adrenal suppression and multiple sclerosis.

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  With artificial joints, metal pins and silicone implants.

 

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  Avoid alcohol & recreational drugs before a steam

 

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  If you are pregnant or there is a possibility of pregnancy or you’re nursing

 

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  During or after ovulation if you are trying to conceive

 

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  During menstruation or if you experience hot flashes

 

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  With any open wounds, sores, blisters or stitches

 

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  If you have a vaginal infection or fever

 

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  Piercings will need to be removed

 

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  If you have an IUD

 

PLEASE drink plenty of water before you go in and plenty more when you come out.

 

If you start to feel nausea, headache, dizziness, fainting, burning or rapid heartbeat, leave the heat immediately and notify your service provider.

 

Please take a moment to carefully read the following information and sign where indicated.

 

If you have a specific medical condition or specific symptoms, vaginal/yoni steam baths may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner so that the temperature may be adjusted to my level of comfort. I further understand that vaginal/yoni steam baths should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the vaginal/yoni steam bath is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Because vaginal/yoni steam baths should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I forget to do so. I am aware and I understand there is a possibility that my IUD can come out due to a Vaginal Steam Bath. This has been explained to me and I am going ahead with the Vaginal Steam Bath at my own risk. I understand that I am having this vaginal/yoni steam bath at my own risk and hereby release Zion Wellness Center/ The Holistic Womb/ Ahava Bey/Timothy Ruther and its contractors and/or employees from any liability.