BalancEvolutionâ„¢, LLC – Consuelo Cassotti Client InformationName* First name Last name Date of Birth* MM slash DD slash YYYY Gender M F Street Address* City* State* Zip Code* Country* AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cellphone*Email* Profession Health InformationAre you currently receiving any treatment from a Doctor or other Practitioner? (require a Yes or No answer)* Yes No Are you currently taking any medication? (require a Yes or No answer)* Yes No If you like, please give a brief background of your current concern:Session InformationHow did you find about BalancEvolution? (or refer by):*Which session did you book?* Karmic Release QHHT RTT Intuitive Coaching Please provide any additional information that you think might be useful.AgreementPlease read and sign in order to schedule a session.Liability I hereby release Consuelo Cassotti from any liability or claims that could be made against her concerning my mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form.Scope of PracticeI understand that Consuelo Cassotti is not a licensed physician, psychologist, or medical practitioner of any kind and that spiritual healing and hypnosis should not be considered a replacement for the advice and/or services, of a psychiatrist, psychologist, psychotherapist, or doctor. ParticipationI give Consuelo Cassotti full permission to work on me and hypnotize if I required a QHHT or RTT session, knowing that by participating fully an RTT session, it is part of the process to listen my personalized recording for 21-30 days, because it as an important role in my overall success. GuaranteeI understand that although any session from Consuelo Cassotti has an incredibly high success rate, Consuelo Cassotti cannot and does not guarantee results since my own personal success depends on many factors that Consuelo Cassotti has no control over, including my willingness and desire to affect the changes inside of myself. Audio Recording(s) I give, Consuelo Cassotti, full permission to make audio recordings that may include my voice. I understand that if a recording (or recordings), are made during or after my session(s), Consuelo Cassotti retains full copyright over any forms of media that may be produced and distributed to me. Physical ContactI hereby grant permission to Consuelo Cassotti to respectfully lift my arm, touch my shoulder, or rock my head during my session(s) in order to help facilitate the process.ConfidentialityBy signing this form, I consent that Consuelo Cassotti may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested. I also understand that, at any time, Consuelo Cassotti may discuss aspects of my case with other colleagues, my identity is completely confidential always, unless I have given permission otherwise. Consent* I have read and understand, I agree with its contentsFull Name (Signature)* First Please type your full name for this agreement.Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ