Consent
I attest that the above information is true and correct to the best of my knowledge. I further affirm that the information collected on this registration form will only be used for the purpose of this initial interview and general class information. Home Concept Properties, LLC, dba: Yoga Home of Therapeutics, its owner, Sara Alavi will not be responsible for knowing or using this information collected on this student registration form.
I understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction and relief of muscular tension. I understand that I will receive information and verbal instruction about yoga and health. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. It is my responsibility to consult with a physician prior to my participation in the yoga class. I agree to take full responsibility for any risks, loss, claim, injury, damage or liability, known or unknown, which I might incur as a result of participating in the program.
Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I knowingly, voluntarily, and expressly agree to accept full responsibility and assume the risk for my use of or participation in any and all classes, activities, apparatus, appliance, facility privilege or service, of any nature, which is owned or operated by Home Concepts Properties LLC, Dba: Yoga Home of Therapeutics and its owner, Sara Alavi, while engaging in any class or activity operated, organized, arranged or sponsored by The Home Concepts Properties LLC, Dba: Yoga Home of Therapeutics and its owner, Sara Alavi, forever harmless from any and all loss, claim, injury, damage, or liability sustained or incurred by me. I specifically agree to indemnify and hold harmless Home Concepts Properties LLC, Dba: Yoga Home of Therapeutics and its owner, Sara Alavi as to any loss, cost, claim, injury, damage or liability, sustained or incurred by participating in the classes, or through my use of the facilities or equipment of Home Concepts Properties LLC, Dba: Yoga Home of Therapeutics and its owner, Sara Alavi which is caused by an act or omission, whether negligent, intentional or otherwise, Home Concepts Properties LLC, Dba: Yoga Home of Therapeutics and its owner, Sara Alavi. I, my heirs, or legal representative forever release waive, discharge and covenant not to sue The Home Concepts Properties LLC, Dba: Yoga Home of Therapeutics and its owner, Sara Alavi for any injury or death caused by my participation in the yoga class. My signature below constitutes my full acceptance of this waiver.
As a student of this yoga Studio in this yoga class and activity, I will give my highest attention to my well-being and take full responsibility for my own physical, mental and emotional health. I will work with patience and an open mind in the self-discovery and physical yoga process. I am fully responsible for the outcome of my yoga practice and participation in this studio or anywhere that Sara Alavi is teaching. I will keep Yoga Home of Therapeutics and its owner, Sara Alavi informed with any changes in my health IN WRITING.
She also offers and teaches EFT which is “emotional Freedom Technique that is tapping / touching on certain points of the body to promote harmony, balance and relaxation to the body, mind and spirit. I understand that I willingly and voluntarily partake in these practices and hold no one responsible for any adverse reactions that I may have. I also hereby, voluntarily, willingly and happily release Home Concept Properties, dba: Yoga Home of Therapeutics and Sara Alavi, owner from all claims, costs, demands, expenses and causes of action should my condition be aggravated at any time.
YOGA, HYPNOTHERAPY, YOGA THERAPY, MEDITATION, YOGA NIDRA, ENERGY AND REIKI HEALING TECHNIQUES, EFT (EMOTIONAL FREEDOM TECHNIQUE) ARE NOT A SUBSITUTE FOR MEDICAL CARE. IF YOU ARE EXPERIENCING ANY SPECIFIC MEDICAL OR MENTAL PROBLEMS AND HAVE NOT SEEN YOUR MEDICAL DOCTOR OR THERAPIST, WE RECOMMEND THAT YOU DO SO TODAY.
I have read the release and waiver of liability and fully understand its consent. I voluntarily agree to the terms and conditions stated above.
Quantum Tapping or Emotional Freedom Technique (EFT) Disclaimer Emotional Freedom Technique (EFT) or Quantum Tapping is energy-based Therapeutic approaches to healing, which use touch to influence the energy systems. This affects physical, emotional, mental and spiritual health and healing. The goal of this therapy is to restore harmony and balance in the energy system to help the person self-heal. You are being introduced to a self-help method known as EFT or Emotional Freedom Techniques, and/or self- hypnosis, which falls under the umbrella of ‘Energy Medicine’. EFT and other Energy Medicine methods address the underlying energetic patterns of the human body with the intention to help the seeker understand how to bring balance and harmony to your energy system. The theory is that the balance of your body’s electromagnetic system is a critical component for physical, spiritual, and emotional health and well-being.
While EFT and other forms of energy techniques have produced remarkable clinical results, they must still be considered in the experimental stage, and thus, whomever chooses to incorporate these tools must take full and complete responsibility for their use of them.
I understand that any information that Sara Alavi, (Home Concept Properties, dba: Yoga Home of Therapeutics) may provide is only general information and is not to be considered medical or legal advice. I understand that in the session we will use techniques that address the emotional components and energy system of the body. These methods include, but are not limited to EFT or Emotional Freedom Techniques. While there is increasing amounts of research showing the effectiveness of these techniques, EFT is not yet accepted as a mainstream method and therefore, is considered experimental.
Due to the experimental nature of EFT I agree to assume and accept full responsibility for any and all risks associated with utilizing EFT both in and out of a session with Sara Alavi,(Home Concept Properties, dba: Yoga Home of Therapeutics). In no case is EFT intended to diagnose, treat, cure or prevent any disease or psychological disorder. Neither EFT or any other energy based technique that may be used in the session is intended as a substitute for medical or psychological treatment. Any stories or testimonials about EFT are not to be considered a warranty, guarantee or prediction regarding any outcome of any individual using EFT.
I understand that Sara Alavi is a certified Hypnotherapist, Certified Yoga Therapist, Certified Quantum Healing Hypnosis Technique, Reiki Master, as well as a certified EFT practitioner. Sara Alavi, (Home Concept Properties, dba: Yoga Home of Therapeutics) is providing these methods in a non-licensed coaching capacity and accepts no responsibility or liability whatsoever for the use or misuse of the information or techniques presented. I understand that I am strongly advised to seek professional advice as appropriate before making any health related decisions. If I am on any medications, I understand that I am NOT to change any dosages and should consult my physician or the professional who prescribed my medications.
Emotional Freedom Techniques or EFT is based upon the belief that the cause of negative emotions is a disturbance in the body’s energy systems. EFT and other similar methods address the energy system and are intended to decrease the impact of negative emotions upon the body. Energy methods are intended to complement, not replace medical or psychological care.
Because these methods are relatively new, the extent of their effectiveness including risks and benefits are not fully known. While evidence is mounting through scientific studies of the clinical significance of providing positive outcomes, each person responds differently and results vary from person to person in these techniques in addressing many emotion issues.
Please sign below stating that you have been advised of the following:
Hypnosis Consent and Release of Liability Form
1) Reactions may surface during a session that you do not anticipate, including strong emotional or physical sensations or additional unresolved memories.
2) Emotional material may continue to surface after a session and give indication of other incidents that need to be addressed.
3) I understand that gentle touch may be used, with my permission in a face to face session, for the purpose of therapeutic application.
4) By my signature below, given freely and without pressure from any person, I consent to the use of EFT and other energy based modalities within my sessions.
5) I understand that Sara Alavi,(Home Concept Properties, dba: Yoga Home of Therapeutics) is not acting as a licensed medical practitioner, and will not be diagnosing or treating a specific disease.
I have thoroughly considered all of the above and have obtained whatever additional input and/or professional advice I deem necessary or appropriate to make an informed decision before commencing sessions utilizing EFT. I hereby agree to indemnify, hold harmless, and defend Sara Alavi, (Home Concept Properties, dba: Yoga Home of Therapeutics) from any and all claims. I further state that: I have been provided an ample opportunity to read, and have carefully read, the foregoing Release and Waiver, and know the contents thereof and have signed this Release and Waiver as my own free act. I understand and agree that if I initiate any suit of action at law against Sara Alavi, Home Concept Properties, dba. Yoga home of Therapeutics for any loss or injury, no matter how minor or severe, to my person or property, that this document will be used in court. I also understand that by signing this form, I am voluntarily giving up any right I might have to sue or make a claim which I might have or which might subsequently arise or occur in connection with participating in the classes, group sessions or workshops or private sessions at Yoga Home of Therapeutics.
The undersigned Client acknowledges that he or she has been informed of the following information:
Sara Alavi, (Home Concept Properties, dba: Yoga Home of Therapeutics) agrees to provide professional services in accordance with acquired training and experience giving undivided attention during scheduled consultations to facilitate Client's benefits. Services provided utilize induction of hypnosis, and methods and principles used to help clients discover their inner creative abilities, to develop positive thinking and feeling, and to transform undesirable habits and behavior patterns. Client may be taught the use of self-hypnotic techniques to assist in achieving goals and resolving issues that have been mutually agreed upon by Client and Sara Alavi (Home Concept Properties, dba: Yoga Home of Therapeutics).
Hypnosis is not a state of sleep, but is a natural state of mind that can produce extraordinary levels of relaxation of mind, body and emotions. The principles and theories upon which hypnotherapy is based are accessing and utilizing the power of one's inner resources. Hypnosis can transcend the critical, analytical level of mind, and facilitate the acceptance of suggestions, directions and instructions desired by the Client. The therapeutic use of hypnosis can also elicit information and insights from the inner mind. Sara Alavi, (Home Concept Properties, dba: Yoga Home of Therapeutics) utilizes interviews, discussion and hypnotic methods dealing with underlying issues whenever appropriate, with the goal of achieving effective and lasting results.
Services to be provided do not include the practice of medicine, as Sara Alavi (Home Concept Properties, dba: Yoga Home of Therapeutics) is not a licensed physician. These services are non-diagnostic and are complementary to the healing arts services that are licensed by the state.
I consent to participate in the process of hypnosis, with Sara Alavi, Home Concept Properties, dba: yoga home of Therapeutics. I understand that hypnosis can involve the use of techniques such as progressive relaxation, meditation, guided imagery, as well as other helpful methods. As a part of hypnosis, clients are encouraged to recall events, circumstances, behaviors, thoughts, and feelings from prior situations in their life experience. I understand that clients vary greatly in their response to the relaxation and hypnotic process, with some clients experiencing powerful images and recollections, and others experiencing relatively little. Additionally, I am aware that the images and recollections experienced during hypnosis may be a combination of real, imagined, and/or modified memories. I also understand that certain memories and images experienced during hypnosis may represent traumatic events which can invoke intense emotional reactions. These emotionally charged images are often quite useful for facilitating insight and understanding; however, such powerful experiences can nonetheless be emotionally challenging for some clients.
My signature below signifies that I have reviewed the above paragraphs, understand the principal characteristics of hypnosis, and agree to participate in this procedure. Furthermore, I understand that if at any time I become uncomfortable and/or unwilling to proceed with the hypnosis process, that I can request to stop the process and the hypnotic portion of the session will cease immediately.
I, the undersigned Client, acknowledge that I have been advised of the foregoing information, and that I have been given a copy of this “Consent and Release of Liability” form.
Reiki Information and Consent Form
I understand that Reiki Healing or aromatherapy massage is a simple energy technique that is used for stress reduction and relaxation. I understand that Reiki 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 Reiki 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 ailments I may have. I understand that Reiki 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 imbalance in the body sometimes requires multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.
Privacy Notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian specially if the client is under 18.
