Ph#: 407-908-4918 / SJ@HealingSelect.com

Please read this letter prior to coming to the healing.  You will be required to sign this form prior to the first healing session.

Client Information Letter and Consent for Treatment

Scope of Practice
My name is Sundeep Jay and I am a graduate of the Barbara Brennan School of Healing - which is a 4 year school specializing in the teaching of energy healing on individuals. The healing I provide is complementary to other options that are available in the health industry. I do not medically or psychologically diagnose or prescribe treatment and or medical drugs. If you have a physical injury or a disease condition, I ask that you be in the care of a licensed medical professional. I do not advice you to discontinue any medical or psychological treatment you may be receiving.

Type of Healing Work
The Brennan Healing Science that I apply helps to clear and charge the human energy field which surrounds ALL living and inanimate things. The work I will be accomplishing helps remove energetic blocks that may lead to dis-ease and to enhance the body's natural healing capability. I will be doing energy healing work both with my hands on the body and also through the Human energy Field which surrounds the body. This work does not require me to place my hands on your body in order for the healing to work. The work is done with you being fully clothed and lying on the healing table or sitting in a chair. The exact location of the gentle hand placements will be discussed prior to the healing. In general, my hands are placed on ALL of the 7 energy centers (called chakras) that are located throughout your spinal cord and also in the place of discomfort. Please let me know if any area is sensitive. We may also  explore areas that influence your state of well-being, such as your health history, life stressors, belief systems, your family, childhood history, and relationships. Everything you share is confidential.  I do discuss clients (without using real names) with my professional supervisor or peers for the purpose of continuing education. THIS IS NOT MASSAGE THERAPY, NOR IS THERE ANY FORM OF MUSCLE AND OR BODY MANIPULATION. The Sessions will support and facilitate physical, emotional, mental and spiritual health & healing.

Self care is an extremely important part of this work and it is your responsibility during our work together. If at any time during the session you are uncomfortable, please inform me immediately and I will stop the healing work. I also recommend that you refrain from using alcoholic beverages 24 hours prior to and following our session.

ACKNOWLEDGEMENT, CONSENT, CLIENT PRIVACY RIGHTS
I have read and understand the above disclosure regarding the services offered by Sundeep Jay.

We have discussed the nature of the services to be provided including information that Energy Healing is a holistic complementary and integrative energy based therapy that is accomplished through the use of contact and/or non-contact touch. I understand that he is not a licensed physician, psychologist or a massage therapist and that his services are not licensed by the State of Florida. I understand it is my responsibility to maintain a relationship for health with a medical doctor, if I so desire. I further understand that the above named is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies.
I have read and understand the above disclosure regarding privacy policies and confidentiality, and that experiences during these sessions are confidential, but subject to the usual exceptions governed by the laws of the State of Florida and other federal laws and regulations.
I have been informed that Sundeep Jay will not diagnose nor prescribe drugs for any condition that I might have nor does he make any specific claims regarding results from the Healing Sessions that I receive.
My questions have been answered to my satisfaction regarding my Energy Healer's background, a Healing Session, and what I might expect from this and future session.

* Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless, Sundeep Jay from and against any and all claims or liabilities of whatsoever kind or nature arising out of or in connection with my session(s).
 

I fully consent to use the services offered by Sundeep Jay by signing below:

Signed: _____________________________________________ Date: ____________________

Print Name: ___________________________________________________________________

Address: ____________________________________________________________