Informed Consent Form

Your Name

Your Address

Phone

Email address

May I leave a message on your voicemail, text, or e-mail?
VoicemailTextE-mail

What are your intentions/areas of concern for this session?
If you are unsure please type "unsure".

Please read and sign/date below:

I understand that it is the intention of Kelly Wheatley-Alley to assist me in my journey by utilizing energy healing techniques. I recognize that I am responsible for my own well-being.

I acknowledge that energy healing services do not take the place of medical care or psychological care. It is recommended that I see a licensed physician or mental health care provider for any medical or psychological condition I may have.

I understand that Kelly Wheatley-Alley does not diagnose medical conditions, prescribe medications or substances, perform medical treatments, or interfere with the treatment of a licensed healthcare professional.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Kelly Wheatley-Alley against any and all claims or liabilities of any kind or nature arising out of or in connection with my session(s). I understand the nature of these services and am voluntarily participating in them.

For In-home Sessions Only:

By scheduling an in-home session, you acknowledge and agree that you are allowing Kelly Wheatley-Alley from The Glowing Grove into your home for the purpose of conducting the agreed-upon session work. You understand that the work performed during this session is for Reiki and is intended for energy healing, relaxation, etc. You are responsible for providing a safe and comfortable environment during the session. Kelly Wheatley-Alley from The Glowing Grove will take all necessary precautions to ensure a professional and respectful experience.