HILTON HEAD HEALING ARTS

CONSENT FOR TREATMENT
 
The purpose of this consent form is to explain to what I can do for you and what you can expect.
 
My belief about healing is that each one of us is his or her own healer. Healing comes in many forms, but primarily from within. I can assist you in your healing by doing various energy techniques which align and balance your Human Energy Field, which surrounds and interpenetrates your body.  I can also help enhance your sense of well-being using ancient indigenous methods of shamanic healing.
 
We may discuss the major stresses in your life, your belief systems, health history, childhood and other issues that have an effect on your physical and emotional well-being. These discussions will be kept confidential. (Please be aware that I may discuss our work together, with out mentioning your name, with my professional supervisor or a professional peer.)
 
I am not a physician and do not diagnose disease, perform medical examination, prescribe drugs or provide a substitute for medical treatment. I am available as your co-creative partner in your healing process. Our work is intended to be in harmony with any other healing work you undertake. Please feel free to discuss our work with your doctor and health care team.
 
At all times your healing is your responsibility. If at any time during a session you feel uncomfortable please say so immediately. Self care is an important part of your healing process. I recommend that you refrain from alcohol and recreational drugs for 24 hours before and after healing sessions.
 
My fee for a single sixty minute shamanic sessions for Soul Retrieval, Extraction or Divination Healing is $95. For energy healing work, I find that my client and I need a minimum of three sessions to develop a sound healing relationship, starting with a ninety minute session, followed by two sixty minute sessions ten days to two weeks apart. The fee for this opening block of work is $290. Subsequent sixty minute sessions are $95.
  
Please give as much notice as possible if you need to cancel an appointment.
 
I ask for full payment for any sessions canceled with less than 24 hours notice.
 
Many of my clients have experienced increased well-being and improvement in their conditions: some have experienced complete healing, but I cannot promise you these things. I am happy to answer any questions and encourage you to express any concerns. I hope you enjoy this interchange as much as I do .  
 
In signing the attached Acknowledgement and Release, you agree that I may work with you in the above described manner.

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I hereby Acknowledge that I have read pages 1 and 2 of the above information provided by Rev. Carol Jeanne White Tietjen, MA, BD, and am satisfied that I understand her services are not to be construed as medical examination, diagnosis or a substitute for medical treatment. I freely elect to receive these treatments and Release Carol Tietjen from any and all claims of malpractice, non-disclosure or lack of informed consent. I freely assume any and all risks of the treatments presently and hereinafter.
 
Signed         (type your name in below)                  Date:                 

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