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 *
Name
1. Have you experienced any trauma in the past year? *
5. Liability Waiver *
GENERAL I understand that Samhara 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. Samhara 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 Samhara Energy Medicine. I acknowledge my commitment to my self-improvement process. I recognize that a Samhara 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. *Exception: Full moon ceremony tickets may be transferred to another full moon ceremony within 1 year of purchase. 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. For late arrivals to events, we can only admit individuals 10 min after doors close. Rewards We appreciate you sharing about our offerings! To thank you for your sharing, you will receive 10 points for every referral. When you have 30 points, you can redeem them for a $30 credit. Your points are earned after the referred client books a session or event. You must let us know via email to connect@shellyburton.com when you have referred a friend, to claim the points. PRIVATE SESSIONS Payment For in-person sessions, credit card, email transfer or cash is accepted. For phone sessions, payment is accepted by email transfer, credit card or Paypal. HST not included in prices listed. For late payments, you will have 4 days to resubmit your payment. After 7 days, a $20 late fee will be charged. Cancellation 24 hours notice is required for cancellations or changes. The full session fee will be charged if less than 24 hours notice is given. Programs All programs expire after 1 year. If paid in full, sessions can be scheduled at a custom frequency within the program period. If on a payment plan, sessions are scheduled at regular intervals. Payment plan intervals cannot be changed 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 10 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 rate of $222 per hour. Animal Therapy For in-person private sessions, or events held at 50 McMurray Ave, please note there is a gentle and healing Himalayan cat. He loves to greet people, ensure they are grounded and say goodbye before leaving. The house is kept clean and has hardwood floors throughout. If you have allergies, or any concerns, please contact connect@shellyburton.com prior to your session/event. WAIVER, RELEASE & INDEMNITY In consideration of Shelly Burton and Rhythm of Change, 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 Burton and Rhythm of Change 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 Burton and Rhythm of Change or their staff. I further hereby undertake to hold and save harmless and agree to indemnify Shelly Burton and Rhythm of Change 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 connect@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.