Client Acknowledgement &
Consent to Receive Healing Services
Truth is an alternative healing service provider and is not a licensed mental health practitioner, nor are the services Truth provides licensed by the State of California. Truth is a Certified Massage Practitioner #54878, certified by the California Massage Therapy Council (CAMTC) and insured by Associated Bodywork and Massage Practitioners (ABMP). Truth is trained in Massage and Polarity Therapy from Cypress Health Institute and Coaching and Counseling from the non-accredited Interchange Counseling Institute.
Please initial each of these statements:
____ Truth will neither diagnose nor prescribe for any condition or problem from which I may appear to be suffering.
____ Truth has informed me that no guarantee or promises of specific outcomes or cures have or will be made to me, and that any benefits which I experience, come from within.
____ In accordance with state law, Truth has advised me to inform my medical doctor/licensed therapist that I am receiving alternative healing services.
____ Truth has informed me that she is not a licensed physician/mental health clinician. The alternative healing services provided by Truth are not licensed by the State of California nor are they a substitute for licensed medical treatment.
____ I understand that the bodywork I receive from Truth is provided for the purpose of relaxation, relief of muscular tension, increased range of motion and overall well being. If I experience any pain or discomfort during sessions, I will immediately inform Truth so that the pressure and/or strokes may be adjusted to my level of comfort.
____ I further understand that bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
____ Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
____ I assume full responsibility for receipt of bodywork; I release and discharge the practitioner from any and all claims, liability, damages, actions or causes of actions arising from bodywork received. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
I have read and understand the above disclosure about the services offered by Truth and about her training and education. I have discussed with Truth the nature of the services to be provided and all of my questions have been answered. I understand it is my responsibility to maintain a relationship for myself with a medical doctor and/or other licensed therapist and that Truth may recommend that I seek care from additional qualified practitioners. In some cases, if these recommendations are not followed, it may necessitate suspending or terminating our work together. I consent to receive services offered by Truth, and agree to be personally responsible for the fees in connection with those services. I understand that this consent form and waiver of liability will apply to my current and future sessions with Truth Berenson.
______________________ ______________________ ______________________
Name Email Phone
______________________ ______________________
Signature Date
Please initial each of these statements:
____ Truth will neither diagnose nor prescribe for any condition or problem from which I may appear to be suffering.
____ Truth has informed me that no guarantee or promises of specific outcomes or cures have or will be made to me, and that any benefits which I experience, come from within.
____ In accordance with state law, Truth has advised me to inform my medical doctor/licensed therapist that I am receiving alternative healing services.
____ Truth has informed me that she is not a licensed physician/mental health clinician. The alternative healing services provided by Truth are not licensed by the State of California nor are they a substitute for licensed medical treatment.
____ I understand that the bodywork I receive from Truth is provided for the purpose of relaxation, relief of muscular tension, increased range of motion and overall well being. If I experience any pain or discomfort during sessions, I will immediately inform Truth so that the pressure and/or strokes may be adjusted to my level of comfort.
____ I further understand that bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
____ Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
____ I assume full responsibility for receipt of bodywork; I release and discharge the practitioner from any and all claims, liability, damages, actions or causes of actions arising from bodywork received. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
I have read and understand the above disclosure about the services offered by Truth and about her training and education. I have discussed with Truth the nature of the services to be provided and all of my questions have been answered. I understand it is my responsibility to maintain a relationship for myself with a medical doctor and/or other licensed therapist and that Truth may recommend that I seek care from additional qualified practitioners. In some cases, if these recommendations are not followed, it may necessitate suspending or terminating our work together. I consent to receive services offered by Truth, and agree to be personally responsible for the fees in connection with those services. I understand that this consent form and waiver of liability will apply to my current and future sessions with Truth Berenson.
______________________ ______________________ ______________________
Name Email Phone
______________________ ______________________
Signature Date