The Beginning of Something Beautiful

You’ve just said yes to yourself, your healing, and your next-level transformation. That’s a big deal—and it deserves to be celebrated. 🌟

Complete the form below and I will be in touch to discuss if this offering is a good fit for you.

First Name *

Last Name *

Email *

Address *

City *

State *

Phone *

Date of birth *

Time & Date of Birth

Place of Birth (for time zone)

Pronouns

Occupation

Emergency Contact *

Family History *

Medications, Supplements & Substances *

Diagnosis *

Do you have children? *

Sleep Patterns *

Do you wake feeling rested? *

Yes

Therapeutic History *

Rest & Relaxation *

What type of environment did you grow up in? *

Unserving Patterns *

Fun, Joy & Creativity *

Describe your main intention for this healing. *

Is there anything else you would like to share with me?

Ecosophy Pledge

The Ecosophy pledge is founded in the Toltec wisdom of the five agreements. I pledge to be impeccable with my word. I will speak with integrity throughout my Journey. I will remember that nothing anyone else does is about me and that others are living and reacting from their own place of reality. I will not make assumptions but rather, I will ask questions with an open and curious mind. I will listen to others with the intention of understanding, knowing their truth may not be the same as my truth. This pledge is made with the grace of my humanity, imperfectly, but I will do my best.

I Pledge *

Yes

Consent, Waiver & Cancellations

I have, following consultation, consideration and discussion, agreed to undergo this healing. I am fully aware that the services I wish to receive are those of a holistic nature and do not serve as a substitute for professional medical advice, examination, diagnosis or treatment. I accept that no treatment guarantee can be given and it may take several sessions before I notice any benefit. This will depend on my lifestyle, ongoing medication and general health.

Summarized;

1. I understand treatment is of a holistic nature and does not serve as a substitute for professional medical advice, examination, diagnosis or treatment. I understand that my treatment notes include my personal information and health history. Also documented will be any issues discussed, interventions, treatment planning, goals and progress. All records will be kept securely and strict confidentiality is maintained. No authorization of my notes will be released to anyone without my written consent unless required by law.

2. I understand my details are confidential unless I provide written authorization, or they are required by law. I am voluntarily undertaking these healing services, whereby I understand when all care is undertaken by the guide, I accept and assume all risk and responsibility. On behalf of myself, estate and all stakeholders I understand I am waiving my guide and/or their business identity for all liability regarding injuries/damages that could possibly result from these services. I understand this waived liability also relates to any future claims of any kind that may result from undertaking these services in the future as long as these services are competently performed.

3. I understand and accept all responsibility for services received and herby waive and release my guide and associates from any liability past, present and future relating to these services.

Also • I acknowledge that my guide adheres to non-discriminatory practices and guidelines. • I confirm that I have supplied my guide with all known medical conditions, injuries and presenting issues. In the event I may have not then I understand that the guide is not liable in any way • I confirm that I will inform my guide of - Any changes with my health in consideration for treatment planning - Any discomfort at the time of services/treatment or before and after session. • I am committed to achieving my desired goal with my guide. It is also up to me to ensure that I reach out to my GP or equivalent, or local emergency hotline if I feel I need more support.

Cancellation Policy; I understand that missed or rescheduled sessions without 24 hours' notice will be forfeited without a refund. Refunds are not provided once sessions begin. Emergencies will be accommodated as best as possible.

Signature *

Clear

The Beginning of Something Beautiful

ECOSOPHY WELLNESS - ALL RIGHTS RESERVED - TERMS & CONDITIONS