Clients

Client Intake and Consent Form

Name *

First

Last

What is your age? *

Email *

Phone Number *

Session Options *

Just do the session by proxy then email me the results Phone session Facetime/Skype session In Person session

1. Issue you would like to work on: *

2. Issue you would like to work on *

3. Issue you would like to work on *

4. Issue you would like to work on *

Additional Comments *

Have you paid for your session? *

Yes Not Yet

The Emotion Code Consent Form

1. I understand that The Emotion Code, as well as the Body Code System, as taught by Dr. Bradley Nelson, (hereinafter called "these methods"), and as practiced by Shannon Flores, seek to identify and eliminate underlying energetic imbalances in the areas of energy, circuitry, pathogens, structure, toxicity, and nutrition. These methods of energy healing promote harmony and balance within, relieving stress and supporting the body’s natural ability to heal. Energy healing through these methods is widely recognized as a valuable and effective complement to conventional medical care.

2. I understand that releasing trapped emotions, or the correction of any other energetic imbalance using these methods as practiced by Shannon Flores, is not a substitute for medical care. This information is not intended as medical advice and should not be used for medical diagnosis or treatment. Information received is not intended to create any physician-patient relationship, nor should it be considered a replacement for consultation with a healthcare provider, nor is it meant to replace any medical treatments as ordered by any physicians or any other medical care I have been advised to seek by them. I further understand that these methods are not a replacement for any professional psycho-therapeutic or counseling sessions in the treatment of any mental health issues or disorders.

3. I understand that if my practitioner makes any suggestions regarding supplementation of any kind, such as vitamins, minerals, herbal preparations, or any compounds or any other external remedy of any kind, that I use or ingest any such at my own risk, with the recommendation that I seek the advice of a physician before using any remedy suggested by my practitioner.

4. I understand that in approximately 20 percent of sessions, the release of trapped emotion(s) or other energy(s) may result in "processing," where echoes of the emotion(s) or other energy(s) released may manifest in temporary physical or emotional discomfort, and that this "processing" appears to be a normal part of regaining energetic balance.

5. I understand that my practitioner makes no claims as to healing or recovery from any illness I may have now, nor the prevention of any illness I may have in the future, and that no guarantee is made towards validity. I further understand that the use of any information I receive is at my own risk.

6. I understand that if I have health concerns, I am recommended to seek advice from an appropriate medical practitioner before making any decisions about my health, and that this information is offered as a service and is not meant to replace any medical treatment.

7. I understand that these sessions are confidential, and that any personal information would be used anonymously for educational and research purposes only, subject to any exceptions governed by laws of the State of California, or of Federal laws and regulations, and that identifying personal information such as my last name and city will be deleted to maintain my privacy, unless required by law.

8. I understand that I am advised to be self-informed about this work by visiting Dr. Bradley Nelson's website: www.healerslibrary.com and/or by reading his book The Emotion Code.

9. I understand that by signing this form, I fully consent to participating in Emotion Code and/or Body Code session(s) with Shannon Flores.

Consent Form *

I agree

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