Living Situation (Marital status/pets/alone; home as supportive or stressful? Social, family, personal support?):
What change would you like to see in yourself as a result of this session?
Hobbies & interests:
Spiritual beliefs/practices/affiliations:
Your perceived strengths:
Current self-care practices (exercise, meditation, relaxation, body care, journaling, etc):
Use scale 1-10, with 10 as an extreme issue, to rate areas of concern . Please describe any items rated 7 or above.
Health history (list medical conditions/diagnoses, with dates/years):
Hospitalizations/surgeries/accidents/injuries (date/year/complications?):
Mental/emotional traumas (condition/date/year):
Is there anything else you want me to know? Any questions about me or Healing Touch?
I hereby declare that:
I have been informed of the background and credentials of Jean S. Pruett and that she is a Healing Touch Certified Practitioner and Instructor as well as a Pastoral Psychotherapist and Licensed Professional Counselor.
I also have been informed that she is not licensed to practice medicine in this state and therefore will not make a medical diagnosis nor prescribe any medications. I have been encouraged to consult a licensed medical practitioner as needed and have agreed to take responsibility for my own health care.
I have been informed that Healing Touch is a gentle, complementary energy based approach not intended to replace any other medical care that I may be advised to seek by my licensed health care providers.
I understand that Healing Touch uses light touch and/or no touch to assist my body in its natural ability to achieve health and wholeness.
I have been informed that no specific claims have been or will be made regarding results from the Healing Touch sessions that I receive. Treatment goal(s) will be identified as part of the assessment, and I will have input into the goal setting process.
I have been informed that all client information & records are treated in a confidential manner and that no information will be released to anyone without my prior written consent except in situations governed by law.
My questions have been answered to my satisfaction regarding my Healing Touch Practitioner’s background, Healing Touch, and what I might expect from this session.
I understand that sessions are usually 1-11⁄2 hours and that the fee per session is $50. These sessions are reserved especially for me; therefore, except in cases of extreme emergencies, any cancellation must occur 24 hours prior to the scheduled session or I will be expected to pay the full fee for the missed session.
Except in the case of gross negligence or malpractice, I or my representatives agree to full release and hold harmless Jean S. Pruett from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).
I give my consent to receive Healing Touch from Jean S. Pruett, HTCP/I
By signing my name in the box below, I authenticate that I have read, understand and agree to the terms of the Professional Disclosure Statement and Privacy Policy
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