Client’s Agreement Form | Balance Evolution

Client Information

Name*

First Surname

Date of Birth*

Street Address*

City*

State*

Zip Code*

Country*

Email*

Profession

Are you currently receiving any treatment from a Doctor or other Practitioner?*

Yes
No

Are you currently taking any medication?*

Yes
No

If Yes, please list your medications?

Please provide a brief background of your current concern:*

Session Information

How did you find out about BalancEvolution?*

Which session would you like to have?*

Karmic Release
QHHT (Quantum Healing Hypnosis Technique)
RTT (Rapid Transformation Therapy)

What result are you hoping for from your session?*

Please provide any additional information that you think might be useful for the best possible outcome from your session.

Agreement

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 Practice: I 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.

Participation: I 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 days, because it as an important role in my overall success.

Guarantee: I 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.

Physical Contact: I 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.

Confidentiality: By 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.

Full Name (Signature)*

Please type your full name for this agreement.

Consent*

I have read and understand the client agreement form. I agree with its contents.

Comments

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