CLIENT FORM

Client Information & Consent Form

To ensure a safe, respectful, and professional experience, I kindly ask all clients to complete this form before their scheduled session. This form is intended to gather essential information and provide consent for participation.

It does not require you to share personal intentions or details about your current situation — the healing process unfolds naturally during our time together.

All information provided will remain strictly confidential and is used solely for professional record-keeping and client care.

First Name

Last Name

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

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I understand that Healing energy session is a simple, gentle, energy technique that is used for stress reduction and relaxation. I understand that healing practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Healing energy session does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Healing energy session can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

I acknowledge that Violeta Burja is an Energy Healing Practitioner and is in private practice for the purpose of providing mental/emotional/physical and spiritual support using different energy healing techniques. I also acknowledge that Violeta Burja is not a medical doctor or mental health care professional, and accordingly cannot and will not provide me with medical advice or psychological advice. I will rely on my own medical practitioner or mental health professional for advice for medical or psychological advice. I will rely on Mrs. Burja only for the sharing of important skills and tools involved in increasing my mental/emotional/physical and spiritual awareness through the transfer of loving and compassionate energy. Mrs. Burja is a support person who has been attuned to provide energy healing treatments. She will respond to my inquiries by providing positive reinforcement and appropriate feedback. I acknowledge my overall responsibility to advise Mrs. Burja with respect to my levels of comfort or discomfort and any other information, which might influence her support of me. I recognize that energy healing is only one factor in the management of my health. I also recognize that ultimately it is up to me as to whether I choose to follow the sharing of information and skills provided by Mrs. Burja and that it may be advisable to consult with my medical or mental health professional prior to so doing. In consideration of the services, information, and support I have received or will hereafter receive from Mrs. Burja, I hereby hold harmless Mrs. Burja from any or all liability in consequence of such services, information and support given, and release and waive all claim for damage howsoever incurred or to be incurred, as a result of such services, information and support. This Release shall be effective and binding upon my heirs, next of kin, executors, administrators and assigns. I have read this Release prior to signing and I understand its effect. I am aware that by signing this Release I am waiving certain legal rights, which I or my heirs, next of kin, executors, administrators and assigns may otherwise have had against Releases.

Thanks for submitting!

CLIENT FORM

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