Session Prep

Intake Form

Please fill out the following intake form prior to your first session. Submissions 24 hours in advance are appreciated.

Please complete the form below

Name

First Name

Last Name

Birth Date

YYYY

Phone

With country code (e.g. +1)

Email Address

Location

City, Province/State, Country

Referred by

If referred by a client, who was it? If other, please explain.

1. Have you experienced any trauma in the past year?

Yes

a. If yes, what happened?

2. What is the biggest challenge in your life right now?

a. How long has this been a challenge?

3. If healing allowed you to accomplish only one thing, what would you want that thing to be?

4. List current or recents types of Healing, Therapy, Courses, etc.

5. Join my monthly newsletter to receive new moon wisdom, event invites and a complimentary meditation.

If yes, please check your email and confirm your subscription. We respect your privacy.

Yes

6. Liability Waiver

GENERAL I understand that Shelly Energy Medicine is a stress reduction and relaxation technique. I acknowledge that sessions administered are only for the purpose of helping me relax and to relieve stress. Shelly Energy Medicine Practitioners do not diagnose conditions, nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment I may have. I also understand the body has the ability to heal itself, and to do so complete relaxation is often beneficial. Long-term imbalances in the body require multiple sessions to allow the body to reach the level of relaxation to bring the system back into balance. I understand and believe that self-improvement requires commitment on my part, and that I must be willing to heal if I am to receive the full benefit of Shelly Energy Medicine. I acknowledge my commitment to my self-improvement process. I recognize that a Shelly session program must be followed to be truly effective, just as prescribed medication is only effective if taken as directed. Refunds Purchases are non-refundable and non-transferable. Arrival I am not able to take appointments more than 5 min early. For late arrivals to private sessions, you will have my full attention for the remainder of your slot. Confidentiality Your confidentiality is guaranteed, with only four exceptions: 1. If I believe that disclosure is essential to prevent physical injury to yourself or others. 2. If I am of the opinion that a minor is in need of protection from abuse or neglect. 3. If my records are subpoenaed by court order. 4. A client reports misconduct of another health practitioner. PRIVATE SESSIONS Payment For hands-on sessions, credit card or cash is accepted. For phone sessions, payment is accepted by credit card. Payment is due on session day. After 10 days, an interest rate of 10% per month is charged on late payments. Cancellation 48 hours notice is required for cancellations or changes to private and distance sessions. The full session fee will be charged if less than 48 hours notice is given. Programs If on a payment plan, sessions are scheduled at regular intervals corresponding with the payment dates or later. Payment plan intervals cannot be extended once a program has begun. Extra Time For private sessions, pending schedule availability, we can extend a session to fully meet your needs. After a 5 min grace period, the extra time will be pro-rated. Support Calls For private sessions, if a check-in call is needed for additional support between sessions, this can absolutely be arranged. If you are mid-program, calls are billed by the minute on a pro-rated basis. Calls outside of a completed program are billed at the regular hourly rate. WAIVER, RELEASE & INDEMNITY In consideration of Shelly Energy Medicine or qualified practitioners, agreeing to provide me with energy medicine treatments as specified above, I for myself, my heirs, my executors, administrators, successors, and assigns, hereby release, waive and forever discharge Shelly Energy Medicine and their directors, officers, shareholders, affiliates, associates, employees, agents, servants, contractors, representatives, successors, and assigns ("the Staff") of and from all claims, demands, damages, costs, expenses, actions and causes of action, whether in law or equity, in respect of death, injury, allergic reaction, illness, physical discomfort, loss or damage to my person or property however caused, arising or to arise by reason of the energy medicine treatments, whether as a participant or otherwise, whether prior to, during or subsequent to the energy medicine sessions or events, and notwithstanding, the same may have contributed to, or occasioned by, the negligence of Shelly Energy Medicine or their Staff. I further hereby undertake to hold and save harmless and agree to indemnify Shelly Energy Medicine or their Staff from and against any and all liability by any of them as a result of, or in any way connected with, the energy medicine treatments. If you are under the age of eighteen, please contact us at book@shellyburton.com as this waiver must be signed by a parent or guardian. By ticking the box below, I acknowledge having read, understood and agreed to the above liability waiver, release and indemnity and I warrant that I am physically, mentally and emotionally fit to engage in energy medicine sessions and events.

I agree to the Shelly Energy Medicine liability waiver