Consent Form Non Touch

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First & Last Name*

Name you want to be called (Nickname)*

Date of Birth (legal) if under 18, leave this site *

Phone Number*

Your email address*

Pronouns - Remember we are a relaxed environment! Mr., Mrs., Miss are not required. Our Practitioners prefer to be on a first name basis to keep the environment relaxed!*

Only interested in non touch retreats Yes or No - If interested in a touch retreat click on Touch Retreat Link Below.*

This Retreat, LifeHolist.com Website, Methods, Treatments, Systems, All Information, Practitioners, Holistic Methods/Systems, Reiki Methods/Systems and similar are classified as spiritual healing. The info or meeting does NOT take the place of medical treatments or advice. You understand that healing requires actions and beliefs that are the responsibility of both parties as a result therefore there are no claims or guarantees of healing or curing disease being made. *

I agree to Covid-19 safety protocol, including hand-washing, sanitation, mask usage, and contact tracing if applicable. Should I become ill or experience any symptoms of Covid-19, I will alert the practitioner immediately.*

If this is our first meeting, please provide the name and contact information for one reference. *

Is there anything on your social media that you would like us to keep up with?*

Current Health & Well Being: The following includes questions about your health and state of well-being, as well as an explanation of techniques the practitioner may use in your retreat. Any and all information given is confidential, and is for your practitioner’s information only. It is your choice whether you answer these questions or not; however, the more informed your practitioner is, the more they can fully guide the energy and choose the best techniques to support you and your unique needs during this retreat. Your practitioner does NOT diagnose or prescribe and any information you provide will NOT be used to diagnose or prescribe.

What areas of your body do you tend to hold tension or stress?

Do you have any sustained injuries? Did they require medical attention or surgery?

Do you have any chronic injuries?

Any additional notes to help the practitioner?

Interests-Check All that Apply*

Holistic Healing

Reiki or Energy Healing

Education & Learning

Holistic Coaching or Courses

Reiki Coaching or courses

Behavior Issues

Intimacy Coaching & Support (Couples & Singles)

Financial Coaching

Education & Learning

Pleasure Training (Couples & Singles)

Group Retreats (Indicate which in Message Section Below)

Press & Media

Body Healing

Self Care

Pain Relief

Cancer Prevention Reduction & Healing

Self Hypnosis

Aromatherapy

Reflexology

Natural Remedies Medicines & Supplements

Meditation

Anything Else? Explain in Message section below

Meeting AGREEMENT All (visitors, patients, members, students, participants and similar-hereafter referred to as YOU/YOUR) must sign this Consent form by typing your name for admittance or for entrance plus YOU must be of legal age of at least 18 years of age or age of majority for your state or YOU have committed perjury. This Consent form is also required to participate or attend any (personal/private retreats, group meetings, courses, classes, events, retreats or similar herein after referred to as RETREATS). YOU understand that our RETREATS may bring up issues or similar of a highly personal nature that may cause YOU to experience emotional or physical responses that may be unexpected and/or unpleasant. Further, YOU understand that YOU may experience mental, emotional, physical, spiritual distress or similar distress and that such distress may cause unpleasant feelings. What is experienced in this RETREATS may create a physical response or similar on YOUR part or the part of other participants. YOU understand that there is always the risk of an accident, injury, and emotional distress or similar. YOU agree to assume this risk, including but not limited to the types of responses before described. YOU confirm that YOU do not suffer from any mental or physical impairment and have not been diagnosed at any point with a disorder, condition, injury, either physical or mental, that might make it inadvisable for YOU to assume such risks. This RETREAT is not a substitute for therapy or a substitute for any other form of professional consultation. By signing below, YOU willing agree to the preceding statements and hold harmless from all liability, Lifeholist.com, Lifeholist, LLC, the facilitator, the event organizer, the event host, any other organizers, those from whom space is being rented, and all participants attending this meeting. YOU understand that YOU may leave the meeting at any time for any reason. CONSENT & ACKNOWLEDGEMENT understood by writing YOUR name below, YOU acknowledge YOU have read all these items and agree to terms of use, privacy policy membership agreement in addition to this New Member Consent Form & Retreat Protocol form, and certify all information is true and correct to the best of YOUR knowledge and YOU agree to be bound by these*

Complete the New Patient/Member Consent Form below with your Retreat Interests & contact info! Some Practitioner Retreat may require a deposit to confirm booking date & time or add any follow-ups or aftercare. If you are not over 18 years of age or over the age of majority for your state, your parent/guardian must make your appointment for you.

Some Holistic treatments require methods to heal the WHOLE person! So whatever your interests are, we are here for you! In order to insure that we get you to the practitioner that best suits your needs and interests, this consent form reflects some but not all interests we treat! We look forward to meeting you!

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This site is presented for information purpose only and is not intended to substitute for professional medical advice. Lifeholist® and Life Holist® are registered trademarks of Lifeholist, LLC formally LifeHolistic.com of TX. ALL RIGHTS RESERVED 2016-2023

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One or More Interests-Check All that Apply*

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