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Release of Liability Waiver



I hereby request and consent to the performance of energy healing modalities and treatments within the scope of the practice of Rose Falgout All Light Connection (or on the patient named below, for I am legally responsible).



I understand that methods of treatment may include but are not limited to: counseling, coaching, energy balancing and harmonization, ThetaHealing™, intuition, chakra harmonization’s, energy healing, past life, in-between and future life journeys, meditation, visualizations, integration, soul-retrieval. I will immediately notify RFALC of any unanticipated or unpleasant effects associated with any of the energy modalities applied.


I have been informed that energy medicine is a generally safe method of treatment, but that shifts in energy occur and may create some physical, emotional, or spiritual side effects which may include physical tingling, feeling lighter energetically, mild fatigue, nausea, muscle soreness, headache, thirst, changes in relationships, shifts of perception, etc. I do not expect the energy practitioner to be able to anticipate and explain all possible risks and complications of energy treatment, and I wish to rely on the energy practitioner to exercise judgment during the course of treatment which the energy practitioner exercises a best and highest interest for healing, based upon the facts then known and for my best interest and highest good.  I understand that results are not guaranteed.


I understand that all clinical information and records of energy healing treatments etc. will be kept confidential and will not be released without my written consent.


By voluntarily checking box on web site, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of energy medicine and intuitive energy healing and other energy modalities, and have had an opportunity to ask questions.  I intend this consent form to cover the entire course of my energy treatments for my present condition and for any future conditions(s) for which I seek any energy healing modalities.

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