Client Intake & Consent Form

Personal Information

Address * Cell Phone * Home Phone Email *

Attachments (Optional)

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Emergency Contact

Name * Phone * Relationship *

Restrictions

Check any that apply.

Health History

Have you had surgery recently? Have you been diagnosed with Lymphedema? Describe affected areas: Have you ever had surgery on your abdomen, chest, or back? Have you had lymph nodes removed? Is there anything else we should know before starting therapy? Immuno-suppressants you take: Allergies (pharmaceutical & environmental): Healthcare provider’s name: Current medications:

Dietary Style

Other

Scales

Stress (1 = no stress, 10 = extreme) Type(s) of stress Pain (1 = no pain, 10 = extreme) Pain location / type Energy (1 = no energy, 10 = great energy) Client signature *

Notice of Privacy Practices

The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their client’s consent for uses and disclosures of health information about the client to carry out treatment, payment or health care operations. As our client, we want you to know that we respect the privacy of your personal medical records and that we will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest. We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not clients), and may have to disclose personal health information for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing.

Privacy Acknowledgement

I, *, have received and reviewed a copy of WholeSoul Wellness Notice of Privacy Practices.

Signature of client or guardian * Date *

Client Waiver — Assisted Lymphatic Therapy

I, *, hereby acknowledge under oath that I am the Client of WholeSoul Wellness, LLC and I hereby give my permission to participate in Lymphatic Therapy, RBTI, Wellness Consultation, Shamanic sessions, and any other services offered by WholeSoul Wellness, LLC. As an integral part of such permission, I recognize that Lymphatic Therapy is a naturalist, experimental, alternative procedure whose purpose is not in diagnosing, healing, or curing; but to help promote good health and well-being. Therefore, I hereby agree to hold WholeSoul Wellness, LLC harmless from and against any and all claims, demands, liabilities, actions, causes of actions, damages and/or expenses, of any nature and kind without limitation, arising from my direct or indirect participation in any of the aforementioned therapies. I hereby acknowledge that I assume the risk of any and I will assume all damages if ever needed. I waive any cause of action that I might have at any time against WholeSoul Wellness, LLC or that I might thereafter accrue as a result of any therapeutic services. I have had an opportunity to review this waiver and ask any question concerning its meaning or intent. I verify that I have read this entire document, have had reasonable opportunity to ask questions concerning its application, understand its contents, and acknowledge that the various information provided throughout this document is accurate and complete. I further acknowledge and verify that I have full legal authority to execute this document and there are no requirements, conditions, or obligations, legal or otherwise, which would require the consent or assent of any other person or entity.

Signed this the * day of *, 20 * Signature * Printed name *