It's helpful to know if you are under the care of other practitioners. Sometimes it is possible to coordinate care, with your consent.
Please include the name, type of practitioner, address and contact information for them.
EAST ASIAN MEDICINE QUESTIONS
See the descriptions under each question and please give a detailed response to each category.
HISTORY OF BODY & EMOTIONAL SAFETY
The following questions are of a sensitive nature. Only answer what you feel comfortable answering. Our bodies tend to store held emotions that may start to "wake up" as we access them in mindfulness. Because of this, it is helpful for us to know your history so that we can create the safest and most respectful environment possible for you.
Have you had a traumatic experience (sexual, physical, emotional, verbal or otherwise)?
LIFESTYLE, EMOTIONAL & SPIRITUAL
Share a few words about your family of origin and your home environment growing up. We will have time to explore this in session. This can be a small introduction so I can know a little more about where you're coming from. Please include any psychological and medical conditions.
I am aware of the contraindications of various modalities that may be practiced listed below. By signing this form, I agree that they do not currently apply to me.
You should NOT these modalities if the following contraindications apply to you
❂ Severe mental illness
❂ A mental health emergency
❂ Sever effects of trauma that may do better with more specific counseling modalities
Please take a moment to carefully read the following information and sign by typing your initials below. If you have a specific medical condition or specific symptoms, any of these modalities may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner.
I further understand that these modalities should not be construed as a substitute for medical examination, therapy, diagnosis, or treatment and that I should see a physician, therapist or other qualified medical or counseling specialist for any physical or mental ailment of which I am aware.
I understand that the practitioner facilitating the healing is not qualified to diagnose, prescribe, and/or treat any physical or mental illness, and that nothing said in the course of any session given should be construed as such. Because each of the above named modalities should not be performed under certain medical conditions, I affirm that I have stated all of my known medical and psychological conditions, and answered all questions accurately, completely, and honestly.
I agree to keep the practitioner updated as to any changes in my medical profile and understand that
there shall be no liability on the practitioner's part should I forget to do so.
I understand that I am proceeding to receive any of these healing modalities at my own risk and hereby release Jeevan Singh from any liability.
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