Intake Form

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

 

Please complete the form below

Name *
Name
Birth Date *
Birth Date
Phone *
Phone
If referred by a client, who was it? If other, please explain.
Liability Waiver *
GENERAL I understand that Samhara Energy Medicine is a stress reduction and relaxation technique. I acknowledge that sessions, ceremonies or events (hereby referred to as “treatments”) offered 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. Refunds: Purchases are non-refundable and non-transferable. Arrival: We are unable to admit arrivals after the doors close. Images: I hereby release my image should photos be taken in group activities that may later appear on future media, for websites, social, or any press purposes. WAIVER, RELEASE & INDEMNITY In consideration of Shelly Burton 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 Burton and Shift Point Inc 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 treatments, and notwithstanding, the same may have contributed to, or occasioned by, the negligence of Shelly Burton and Shift Point Inc or their staff. I further hereby undertake to hold and save harmless and agree to indemnify Shelly Burton and Shift Point Inc 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 treatments.