CLIENT INFORMATION & WAIVER

Soul Center Holistic Health LLC

Please complete the electronic waiver form or print & bring a copy to bring to your first session.

CLIENT NAME: __________________________________________

ADDRESS:________________________________

CITY:___________________________

STATE:__________ ZIP:______________________

PHONE: __________________________________

DOB: ____________________

EMAIL: ______________________________________

Would you like to join our Mindful Newsletter? Stay connected for future healing events, you may unsubscribe anytime.  Yes, Please____ No, Thanks____

Medical (Injuries, physical limitations, ailments, surgeries, allergies, restrictions*)     Yes____ No____

If Yes, Please explain:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

*EMERGENCY CONTACT (Name/Phone#): ___________________________________________________

Reiki is a Japanese technique for stress reduction and relaxation that helps promote Divine healing. It is administered by a Reiki practitioner, sometimes using healing hands on touch based on the idea that unseen Life Force Energy flows through us, sharing in energy. Are you comfortable with being touched or adjusted during your Session? 

Yes____ No___

Aromatherapy is the use of fragrant essential oils to promote healing and well-being for therapeutic purposes, through inhalation or bodily application (as by massage). Are you ok with the use of Aromatherapy in your Session? 

Yes____ No____ If you are sensitive to specific aromas please describe: 

By this Waiver, I agree to participation in Yoga classes, Aromatherapy, Workshops, and/or Reiki Healing organized by Soul Center Holistic Health LLC, such participation includes therapeutic techniques including meditation, yogic breathing, healing touch, and performing various yoga postures. By signing my name below, I acknowledge that my participation in yoga classes or any other exercise class exposes me to a possible risk of personal injury. I am fully aware of this risk and hereby release Soul Center Holistic Health LLC, and/or any persons who may teach/heal through SSHH LLC, from any and all liability, negligence, or other claims, arising from, or in any way connected, with my participation in yoga, healing, and the use of essential oils. My signature further acknowledges that I have signed this Agreement freely, voluntarily, and under no duress, and this waiver is binding on me, my heirs, my spouse, my children, my legal representatives, my successors, and my assigns to release considerable future legal rights. My signature verifies that I am physically able to participate in yoga classes and/or massage, reiki healing, or any other form of healing and/or exercise classes, and a licensed medical doctor has verified my physical condition for participation in these forms of healing treatments. If I am pregnant, or become pregnant, or am post-natal, my signature verifies that I am participating in yoga, or any other exercise or healing modality, with my doctor’s full approval as well as my own. I realize that I am participating at my own risk. I understand that these therapeutic techniques are designed for stress reductions & relaxation and do not diagnose, treat, or prevent any conditions or ailments and do not interfere with treatment by a licensed medical professional. I understand that these services can compliment any medical or psychological care I may be receiving. I acknowledge that long-term imbalances of the body may sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to naturally heal itself.   **Please Initial __________

Acknowledgment of Medical Advice
Client acknowledges that yoga and any therapeutic techniques provided in sessions are not a substitute for medical treatment or advice. Client affirms that they have consulted with a licensed medical professional before participating or have voluntarily chosen to participate at their own risk. The Instructor is not a licensed medical professional and does not provide medical diagnoses, treatment, or prescriptions.

Assumption of Risk
Client understands that participation in yoga and therapeutic techniques involves physical movement and may carry inherent risks, including but not limited to injury, emotional or physical discomfort, or exacerbation of pre-existing conditions. Client assumes full responsibility for their participation and any resulting consequences.

Waiver of Liability
Client hereby releases, waives, and discharges the Instructor, employees, agents, and affiliates from any and all claims, demands, or causes of action, arising out of or related to participation in the sessions, including but not limited to personal injury, illness, emotional distress, or property damage, whether caused by negligence or otherwise.

Indemnification
Client agrees to indemnify and hold harmless the Instructor from any claims, losses, liabilities, damages, costs, or expenses (including legal fees) that may arise from their participation in yoga or therapeutic techniques.

Voluntary Participation
Client affirms that participation is voluntary and that they may stop at any time if they feel discomfort or require medical attention.

Governing Law
This Agreement shall be governed by and construed in accordance with the laws of the state of New Jersey without regard to conflicts of law principles.

Severability
If any provision of this Agreement is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Agreement Acknowledgment
By signing below, Client acknowledges that they have read and understood this Agreement, and voluntarily agree to its terms of therapeutic services performed by Rachel Lee Cronin, Soul Center Holistic Health LLC,

Client Signature: ___________________________________________________ Date: __________________________

(Guardian’s Signature if under 18)

Printed Name of Client: _________________________________________________________________________   

(Guardian’s Name if under 18): ___________________________________________________ 

Photography Permission:

With this signature below, I hereby grant Soul Center Holistic Health LLC, and it’s legal representatives, permission to use and publish photographs or video images of me, or in which I may be included, for any purpose authorized by Soul Center Holistic Health LLC, including but not limited to: website use, advertising use, and personal. This grant includes the right to modify and retouch images in discretion of Soul Center Holistic Health LLC. I understand that the circulation of such materials could be worldwide and that there will be no compensation.

Name: _____________________________________________

Signature: _____________________________________________

Guardian’s Signature if under 18:______________________________