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General Intake Form

General Intake Form

Informed Consent and Liability Release 

Intuitive or Mind Body Healing fits into the category of complementary or alternative wellness modalities. It is an educational guidance to self-help life improvement that intends to discover supports for imbalances with mental, physical, spiritual and emotional well-being. Mind/Body or Intuitive Healing is not a replacement for conventional medical treatment, but rather is supplementary to it. The processes of Mind/Body Healing is not specific to any age, sex, race, color or creed or religion.

1. I understand the above statement in regards to services offered and give permission to Julie Stone to perform such services – private or group sessions or education - as outlined above. I understand that it is my choice to follow any recommendations provided.

 

2.  I have or will disclose any information (health or otherwise) that may alter the effectiveness of services offered.

3. I acknowledge that the Julie is not a counselor, psychologist, psychiatrist or physician of any kind. I understand that Julie is not licensed to diagnose illness, disease or any other physical or mental disorder.  I clearly understand that any type of Mind Body, Intuitive Healing or nutritional/herbal education used including but not limited to Theta Healing, Laying of Hands or Guided Meditation is not meant to diagnose, treat or be a substitute for a medical examination and or treatment. l or my representative(s) agree to full release and hold harmless (Julie Stone) from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s) or educational information."

 

4.  I understand that I need to visit my personal physician for any ailments that I may be experiencing.

5.  I acknowledge that no assurance or guarantee has been provided to me as to the results of the private or sessions, education or classes or literature.

6. I understand that if at any time I feel discomfort or have a problem with the session, it is my responsibility to voice my concerns.

7.  I understand that payment is required prior or at time of services offered:  I agree to give 24 hours­ notice for cancellation to avoid a cancellation fees. At any time during a session or class - I can request to stop the session or leave the class, though this may not entitle me to a refund.

Professional Wellness Alliance Membership Agreement

Julie Stone is a licensed provider of the Professional Wellness Alliance, (PWA) a private member community Provider Number: PWA-4621116.

Who We Are:  The Professional Wellness Alliance is on a mission to assure that holistic providers have a defendable basis for offering their services and to bring individuals and families together with PWA licensed providers to learn ways to have the best in health.


How it Works: Licensed providers, Individuals and families join in a private member community to share the services defined below. The PWA is structured as a private community that requires licensing for providers to assure provider ethics, competency, and quality services along with good community order.


Services Provided: PWA licensed providers are authorized to assist members through health education, instruction and products.


Services Not Provided: PWA licensed providers do not offer any state licensed health services, DO NOT take responsibility for the health of any person or for the diagnosis, treatment or resolution of any symptom or condition.

Agree that Provider Members (PWA Licensees) provide only the services described above under “Services Provided” and that these are self-help and educational services not medical services. 

1. Agree that all records of services you receive are available to you upon request as “private member educational records” and not medical records;

2. Agree that the Professional Wellness Alliance does it’s best to assure the integrity and competence of Provider Members (Licensees) and while Licensees represent the PWA mission, that they are independent educators that do not work for the PWA. Therefore, you agree to hold the PWA and affiliates harmless in all matters related to your association with PWA, affiliates or Provider Members;

3. Agree to make your best efforts to resolve any and all complaint you may have with another member with them personally and in the event you are unable to resolve satisfactorily, agree to settle any dispute or complaint through binding arbitration through a mutually agreed arbitrator;

4. Agree that any and all content on the PWA website, newsletters, writings, affiliate links or otherwise are for educational purposes only and are not intended as medical advice.


Term and Cancellation: Membership in the PWA shall begin when you agree to this Membership Agreement and shall terminate with written notice from you to the PWA or from the PMA to you. The PWA reserves the right to deny or terminate membership of any member without cause. Termination shall not waive or relieve you of any obligations or agreements made while you were an enrolled member.

By placing your signature below you accept membership and agree that this agreement is a “contract” binding you to follow the herein terms.

Client/Member Background

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