QHHT Consent Waiver | Pellucidity

Quantum Healing Hypnosis Technique (QHHT) SessionInformed Consent to Treat and Liability Waiver & Release

RELEASE OF ALL LIABILITY

In exchange of completing this form, Alison May & Samantha Beikman and the practitioners of Pellucidity LLC are providing a service assisting you in mind, body, spirit integration through the use of modalities that may include, but not limited to: reiki treatment, sound baths and healing, guided meditations and imagery, chakra balancing, private consultations, yoga, wellness coaching, and energy work.

You, the participant, hereby agree to assume all risks associated with any outcome resulting from your participation in Pellucidity LLC programs or classes or private consultation with their practitioners. Side effects may include, but not limited to: emotional release, lightheadedness, mild fatigue, physical tingling, and change in body temperature.

All information and mental or physical activity or guidance and direction are provided during programs, classes, or private consultations to enhance the well-being of you, the participant. It is my responsibility, as participant, to inform the practitioner if any discomfort should arise. It is my responsibility, as participant, to notify the practitioner ahead of treatment of any pre-existing medical conditions or injuries.

By signing this Waiver and Release of liability you agree that neither Alison May, Samantha Beikman, Pellucidity LLC practitioners nor Pellucidity LLC shall be responsible for any negative consequence of any kind which is claimed to result from:

1) your participation in any of these programs, activities or consultations; or

2) from the use of any information learned or obtained during these programs, activities or consultations, including, but not limited to, reiki treatment, guided meditations and imagery, sound baths and healing, chakra healing, energy work, yoga, wellness coaching, or private consultation provided during Pellucidity LLC programs, classes, or private consultations.

By signing this Waiver and Release you further agree not to assert any legal claims of any kind in any form against Alison May, Samantha Beikman, or Pellucidity LLC on any asserted negative consequence resulting from your participation in these programs, classes or private consultations.

By signing this Waiver and Release you acknowledge and agree that Alison May, Samantha Beikman, or Pellucidity LLC disclaim all liability for any injuries or negative consequence claimed by you to be the result of your participation in these programs, classes, or private consultations.

MISSION OF PELLUCIDITY CLASSES AND PROGRAMS

It has long been our vision to provide the community with a space devoted to the art of holistic & energy healing. We believe there is a strong connection between mind, body, spirit and the overall well-being of an individual. To that end, we employ techniques such as Reiki, meditations, and sound therapy through gongs, singing bowls, and other instruments to promote relaxation and balance. Our hope is to ignite a journey of self-discovery and an expansion of consciousness that will contribute to life-long health and healing.

Client/Guardian First Name

Client/Guardian Last name

Phone

I, (the client), understand if I suffer from epilepsy or from psychotic illness it is NOT generally recommended to undergo hypnosis or hypnotherapy. I hereby agree that by signing this form that I do not suffer from these disorders. *

Scope of Practice I understand that Alison May is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnosis should not be considered a replacement for the advice and/or services of a psychiatrist, psychologist, psychotherapist, or doctor. *

You understand that a QHHT session may include taking you through your current life, possibly other dimensions, parallel lives, and past lives that your higher self (subconscious) wants you to know and learn from. *

Please select who will be participating.

Minor's Name

Audio Recording(s)- I give Alison May full permission to make an audio recording that will include my voice. I understand that when a recording (or recordings) are made during my session(s) Alison may retain a copy for her records where it will remain strictly confidential unless I give written permission for it to be used publicly *

Please specify anything we should know about

I declare that the info I’ve provided is accurate & complete

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program.

By checking this box I certify that I am submitting an electronic signature to Pellucidity LLC and providing an electronic signature to their Informed Consent to Treat and Liability Waiver & Release document. If signing for a minor, I am providing my parental consent. *

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Quantum Healing Hypnosis Technique (QHHT) SessionInformed Consent to Treat and Liability Waiver & Release

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