Client Disclosure and Consent form Life Spirit Healing
Adora Deva, CCHT, CMT
Welcome to my practice. The services I offer are Light Therapy ,Oxygen Therapy, Hypnotherapy, Theta Healing, Massage and Energy Medicine. I customize my sessions to meet my client’s needs. There is a direct connection between the mind, the body and our actions and reactions. All processes are offered to bring about wellness, rejuvenation, stress release, awareness, nurturing as well as skills and resources to free people from their past conditions. You understand that my therapy should not be construed as a substitute for medical examination, diagnosis or treatment and that you should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that you are aware of.
Client privacy and confidentiality are maintained at all times.
I stay current with information and techniques by reading and by taking continuing education every year.
My requirements of my clients:
I understand that to miss or be late f0r my appointment time without 24 hour advance notice inhibits others from filling that time. Therefore I agree to pay full price for missed appointments with less than 24 hour notice.
My training in the healing arts includes:
Reiki Master Certification – 2001
Hawaiian Temple Bodywork Lomilomi – 2002
Bio-Genesis Crystals – 2004
Clinical Hypnotherapy Certification – 2006
Universal Life Minister Ordination – 2006
G5 Therapeutic Massage System – 2008
Chi-Aura Integration Practitioner Certification – 2008
Advanced Light Therapy Technology Training – 2008
Assistant in teaching 200 hour Hypnotherapy Course 2006 – 2008
Integrative, Therapeutic Massage and Polarity Therapy – 2009
Young Living Essential Oils Training – 2008
Emotional Freedom Technique- 2010
Advanced Theta Healing Training-2015
For Bodywork/Energy work and Light therapy please remove all jewelry before session. For Light Therapy please keep your eyes closed, although looking at the light will not harm you. Please also let me know if blinking light bothers you or if you would prefer a mask for your eyes.
For all clients:
I understand that Adora Deva is not a medical practitioner. She does not diagnose illness. I acknowledge she is a wellness practitioner and stress management facilitator. I understand that all information is given for educational purposes and is in no way prescriptive in nature.
Signed ______Date ______
Hypnotherapy Clients:
Some of my services are alternative or complementary to healing arts that are licensed by the State of California. California state law requires that you acknowledge receipt of the information provided in this form and you sign it. You will receive a copy and I will keep the original in my records for at least three years. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you these services, subject to requirements and restrictions that are described fully at the bottom of this page.
Acknowledgment and Consent to Receive Services: I have read and understand the above disclosure about Hypnotherapy and related services by Adora Deva. Although Adora Deva is a Clinical Certified Hypnotherapist, I understand that Adora Deva is not a licensed physician and Hypnotherapy is not licensed by the state.
Signed ______Date ______
California Senate Bill SB-577
What it means for patients and clients
California Senate Bill SB-577, which was signed by the governor in September 2002, has profound implications for the practice of alternative forms of health care in California. AB-577 enables alternative and complementary health care practitioners to provide and advertise services legally.
What does Senate bill SB-577 mean to you the patient and client?
SB-577 gives you access to alternative and complementary health care practitioners. You must be given information about the nature of treatment and the practitioner's qualifications. Feel free to ask a practitioner any question you might have about your treatment. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet you health care needs.
Here are the things that unlicensed alternative practitioners are not allowed to do:
Perform surgery; use x-ray radiation; prescribe prescription drugs; set fractures; treat wounds with electro-therapy; put you at risk of great bodily harm, serious physical or mental illness or death; imply in any way that they are a licensed physician.
In addition, an unlicensed alternative practitioner must do the following things:
Provide a statement, written in plain language that includes the following information:
(1) that they are not a licensed physician and that their services are not licensed by the state,
(2) a brief and clear description of the kind of services they provide,
(3) a description of their education, training, and experience,
(4) ask you to sign an acknowledgment that you received the above written statement
and provide you with a copy of it, as well as keep it for three years.