Client Consent and Disclosure Statement (Please print page, sign and date)
Thank you for your interest in working with Quantum Energetic Healings LLC and our practitioners, Gene Foster and Shirley Bunnell. We are providing you with the following information so you can make an informed choice about your decision to engage our services. Our work together will include a shared understanding of what you hope to accomplish and agreements for supporting those outcomes. As an intentional and conscious participant in your growth, you will ultimately take all responsibility for and actions related to your health and well-being.
Theoretical Approach/Services Offered In our practice we use several innovative techniques and methods which you have the option of using individually or collectively as part of working together. We offer energy sessions and energetic testing of the organs and systems within the body, Biofield-Tuning sessions, Ajna Light Therapy sessions, Conscious Coaching, Aromatherapy and Pure Certified Therapeutic Grade Essential Oils, meditations, intuitive advice/coaching, and sound healing. The prevailing premise of energy work is that the flow and balance of the body’s electromagnetic and more subtle energies are important for physical, spiritual, and emotional health, and for fostering transformation. As intuitive practitioners of the healing arts, we use techniques to balance our clients’ energy systems and to communicate spirit to spirit with our clients. If you ever have questions or concerns about the nature of the theories and methods we use, please feel free to ask us for further resources or references.
The techniques we use in our practice are considered “alternative” or “complementary” to healing arts that are licensed by the State of California. Although we have extensive experience in the healing arts, we’re not licensed in the State of California as a physician, psychologist, or other licensed health care provider nor are our services licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, we can offer you our services, subject to the requirements and restrictions that are described fully in the attached Client Information Sheet incorporated herein by reference and made part of this Client Informed Consent and Disclosure Statement.
Outcome Expectations / Risks & Benefits The intuitive methods we use appear to result in positive outcomes and clients have found them to be effective and beneficial. However, it is impossible to guarantee any specific results regarding your goals using any of the techniques or products we offer, and we don’t know how you will personally respond to any of the techniques. However, we will work together to achieve the best possible results for you.
The clinical reports from energy work show no significant side-effects when used appropriately. However, please be advised that in our work together it is possible to experience some emotional distress and/or physical discomfort or additional unresolved memories may surface related to prior life experiences which could be perceived as negative side effects. Emotions or physical discomfort may continue to arise after a session and you are encouraged to discuss such emotions or physical discomfort with us and, if appropriate, we can refer you to a licensed health care professional for further assistance.
Other Important Information Our work with you as an intuitive counselor/adviser and energy balancing practitioner is not intended to be used to diagnose, treat, cure, or prevent any disease or psychological disorder; our sessions together do not replace the advice and/or services of health care professionals. You agree to consult with your health care provider for any specific health care problems and understand that we may suggest you contact your professional health care provider if we believe it’s advisable. In addition, you understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing any of your health care professionals or using prescribed medication, if any, without consulting with your health care professional, even if after a session it appears and indicates that such medication or treatment is unnecessary. You agree to take full responsibility for your self-care in the, emotional, mental, physical, and spiritual dimensions of your life. You agree to contact us directly if you have any concerns about your experiences with your energy sessions and/or our relationship as practitioner and client.
Acknowledgment and Consent to Receive Services By signing this document, you agree that we have disclosed to you sufficient information to enable you to decide whether or not to engage our services. You understand that you are freely choosing to take advantage of our intuitive counseling and energy balancing services and would otherwise have the option of using another practitioner of your choosing. You understand that your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. Further you understand the extent of energy work effectiveness as well as its risks and benefits are not fully known and you agree to assume and accept full responsibility for any and all risks associated with using energy work. You represent that you’re competent and able to understand the nature and consequences of our proposed sessions.
You have read and understand the above disclosure about the services offered by us and our training and education. You have discussed with us the nature of the services to be provided and you understand our services as an intuitive counselor and energy balancing practitioner are not licensed by the State of California. You agree to be personally responsible for the fees related to the services provided we provide to you. By signing in the space provided below, you knowingly, voluntarily, and intelligently assume these risks and agree to release, indemnify, hold harmless and defend Quantum Energetic Healings LLC, Gene Foster and Shirley Bunnell and their agents, consultants, and employees from and against any and all claims of whatsoever kind or nature, which you, or your representatives, may have for any loss, damage, or injury arising out of or in connection with your sessions.
In order to use our services, California state law requires that you acknowledge receipt of the information provided in this Client Informed Consent and Disclosure Statement. I will keep an original in my records for at least three (3) years.
_______________________________ _______________ Signature Date
CLIENT INFORMATION SHEET [ Legal Information about Complimentary Medicine in California ] In September 2003, California passed ground breaking legislation (California Senate Bill SB-577) which has profound implications for the practice of complementary and alternative forms of health care in California. SB-577 legally enables complementary and alternative health care practitioners to provide and advertise their services to California citizens. However, they must comply with certain requirements specified within the bill which has now become part of California law under sections 2053.5 and 2053.6 of California’s Business and Professions Code.
Sections 2053.5 and 2053.6 of California’s Business and Professions Code provide the following:
A. Provide access to complementary and alternative health care practitioners. You must be given information about the nature of treatment and the practitioner’s qualifications. Please ask your practitioner any question you may have about the treatment options they offer. Ask if you practitioner has been certified by a professional organization and if they belong to any professional organizations. Please tell your physician if you are receiving any alternative treatments. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet your health goals.
B. Requires unlicensed complementary and alternative health care providers to follow certain guidelines and to refrain from certain practices
C. Specifies that unlicensed complementary and alternative health care practitioners are NOT allowed to do:
Perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
Use X-ray radiation
Prescribe prescription drugs, or recommending that you discontinue drugs that were prescribed by a licensed physician.
Treat wounds with electrotherapy
Put you at risk of great bodily harm, serious physical or mental illness, or death
Imply in any way that he/she is a licensed physician.
D. Specifies that complementary and alternative health care practitioners MUST DO the following things: Provide you with a statement, written in plain language that includes the following information:
(1) that they are not a licensed physician and that their services are not license by the state;
(2) a brief and clear description of the kind of services they provide and the reasoning behind it; and
(3) a description of their education, training, and experience.
Ask you to sign and acknowledge that you received the above written statement, and provide you with a copy of it. They must also keep a copy of your signed acknowledgment for three years.