Client Intake/Release Form

CLIENT NAME __________________________________ E-MAIL: ______________________________

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Address_________________________________________________________________________________

Skype Name: _______________________________________________________________________________

Phone (h) __________________ (w)__________________(m)___________________ DOB _____________

OCCUPATION___________________________________________________________________________

What is the main "problem" or challenge you would like to resolve? _________________________________

________________________________________________________________________________________

You will know that this "problem" has had some resolution when____________________________________

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Complete resolution to this "problem" would be__________________________________________________

DISCLAIMER

Integrated Energy Balancing and “Shakti” Margaret Martin  make no claims, implied or otherwise, regarding the success and/or results from the application of EFT, Brain Gym, or Psych-K and/or personal coaching/counseling (hereinafter referred to as “services”) provided by Integrated Energy Balancing and Shakti Martin.  These services are considered experimental and although success rates are in the 80%-90% range, they are as yet undocumented therapies.  Shakti Martin is NOT a licensed physician, therapist or psychologist.  Shakti Martin has received the EFT Cert-1 designation.  The emotional or physical frailty of some people is such that they should not attempt ANY healing procedure without the presence of a LICENSED THERAPIST.  This may be 2% - 3% of the population.  If you are in this category, please consult your medical doctor!  You take full responsibility for your personal health and safety.  Your compliance with all of your current medical treatments, therapies and prescriptions is expected.     Integrated Energy Balancing shall not be liable for any damages or injury arising out of your access to, or inability to access, the services provided.  Integrated Energy Balancing disclaims any and all liability for direct, indirect, incidental, consequential, punitive and special or other damages, lost opportunities, lost profit or any other loss or damages of any kind.

RELEASE

By my signature below, I affirm that the information I have provided above is accurate and true and that I freely enter into this legally binding agreement and acknowledge that I understand and agree with the disclaimer presented above.  Also by my signature, I, and my heirs, in consideration of my participation in the services provided by Integrated Energy Balancing and Shakti Martin hereby release Shakti Martin& her family from any and all liability for any loss or damage caused, or alleged to have been caused, directly or indirectly, by the services provided and/or the information or ideas contained, suggested or referenced during the course of the services provided.  I understand that my participation in the services provided is strictly voluntary, at my own risk and I freely choose to participate.  I understand that Shakti Martin/Integrated Energy Balancing does not provide medical treatments and/or coverage and I verify that I will be responsible for any and all medical costs I incur, directly or indirectly, as a result of my participation.

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CLIENT SIGNATURE                                                                      DATE