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CONSENT FORM
After reading, please print, initial beside each statement, sign the bottom, and bring with you to your first session.


_____I understand that the work offered through SpiritWay Wellness is an alternative and/or complimentary harmonizing/balancing modality. I believe that the body has the ability to make improvements to itself and that long term imbalances in the body sometimes requires multiple treatments to bring the body back into balance. I understand and believe that self-improvement requires commitment on my part, and that I must be willing to change in a positive way if I am to receive the full benefit of the sessions I have requested. I alone am responsible for myself.

 

_____I understand that a session plan will be discussed with me and it is my responsibility to follow through with said plan.  I understand that I may be encouraged increase my water intake, make dietary or sleep changes and that no guarantees of improved physical/mental/emotional/spiritual health are being made.

 

_____I understand that the work I receive should not be construed as a substitute for medical examination, diagnosis, or treatment and that my provider(s) is/are not a licensed nutritional counselor or MD. It is my understanding that the practitioner will not diagnosis conditions nor interfere with the current treatment of a licensed medical professional and that it is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological aliment that I may have.  I understand that nothing said in the course of the session should be construed as diagnosis or prescription and that I alone am responsible to inform myself about my health
 

_____ I acknowledge that sessions administered for me are at my request and I give full permission and I understand that aspects of the sessions may be hands-on. I understand that SPMI (Sadhana/Body Evolve) therapists are not Western medical physicians and that SPMI is rooted in traditional Chinese Kung Fu therapies that sometimes take a course that is the opposite of the western medical model. I understand that because of the nature of the session that bruising or soreness may occur.

_____I do not hold the corporations of Body Evolve (formally Sadhana Therapy) or SpiritWay Ministries, Kimberly Klein, or her apprentices, Sheila Seppi, Dylan Kuczko, helping assistance or associates responsible for my body, myself, or my health status.
 

_____Being committed to this process, I hold harmless the practitioner(s) administering this/these alternative modality(ies) through Spirit Way Ministries.

_____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.

_____It is also understood that any illicit or sexually suggestive remarks or advances will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

 

Signature:____________________________________________________           Date:_____________________