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INTAKE & INFORMED CONSENT FORM

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What information is helpful for Angela to know?

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The following information will be used to help plan safe and eﬀective Energy Work sessions. (Energy Work in this form referes to Reiki, Integrated Energy Therapy®, PSYCH-K®, Emotion Code®, Body Code™, Belief Code®.) Please answer the questions to the best of your knowledge.

Have you ever had an Energy Work/Energy Healing session of any kind before?

Yes

No

If yes, please list modalities and anything you would like me to know about the experience:

I CONSENT TO LIGHT TOUCH during my session (IN-PERSON sessions only)

YES

NO

Are you currently under the care of a physician and/or mental health professional?

Yes

No

I understand that Energy Work is not a substitute for medical treatment or medications, and it is recommended that I work concurrently with my Doctor, Primary Caregiver and/a licensed Mental Health Professional for any condition that I may have. I am advised that if I am sick, I should consult my Doctor. I am aware that Angela E. Gallo, as an Energy Worker, does not diagnose illness, disease, or psychological conditions and does not prescribe medication.

I understand and acknowledge that no guarantees have been made to me as to the effect of the energy work services provided by Angela. further understand and acknowledge that in no way are these services meant to be construed by me as the diagnosis or treatment of disease, but rather as an aid to balancing my energy and to possibly improving my general wellness.

I understand that Energy Work can sometimes result in increased emotional sensitivity, feeling tired and needing more sleep after a session, as well as occasionally cold or flu like symptoms (often referred to as a “healing flu”). I understand these results are temporary and usually resolve on their own within a day or two.

I understand that The PSYCH-K® process is strictly limited to the modification ofbeliefs. The PSYCH-K® process is not designed to diagnose medical problems, nor isit a replacement for medical attention or professional mental health care.

I understand and agree that I am individually responsible for my own life and it’s unfolding. As an expression of my responsibility, I am seeking assistance with the beliefs that manifest my reality through the PSYCH-K® process, but the actual manifestation of that reality is up to me.

If I experience any discomfort during the session, I will immediately communicate that to the practitioner so the treatment can be adjusted or discontinued.

I understand that all cancellations and rescheduling of appointments require a minimum of 24 hours notice.

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

I understand that Angela E. Gallo upholds the highest standards of care and professionalism. As a Preferred PSYCH-K® Facilitator, Certified Emotion Code® and Body Code Practitioner™, abides by the Code of Ethics established by each organization. A copy is available for review upon request.

I attest that I am at least 18 years of age and competent to make decisions for myself.

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