Confidentiality and privacy agreement Survey

1. Confidentiality and privacy agreement

1. The service I receive from Empowerment Healing is to remain confidential and private.

The service I receive from Empowerment Healing is to remain confidential and private. Yes

2. The staff of Empowerment Healing do not diagnose conditions, nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment or condition I may have.

The staff of Empowerment Healing do not diagnose conditions, nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment or condition I may have. Yes

3. Any information or advice given by a staff of empowerment healing is to be used at my own discretion and not as a substitute for medical advice or medication

Any information or advice given by a staff of empowerment healing is to be used at my own discretion and not as a substitute for medical advice or medication Yes

4. I acknowledge that I do not currently have any major psychological problems and that I am not under the influence of alcohol or illegal drugs.

I acknowledge that I do not currently have any major psychological problems and that I am not under the influence of alcohol or illegal drugs. Yes

5. I give the staff of empowerment healing permission to physical place their hands on parts of my body (in a non-sexual way), or to use specified equipment, which is deemed appropriate for the session. Such as hands on stomach or crystals on chakra points

I give the staff of empowerment healing permission to physical place their hands on parts of my body (in a non-sexual way), or to use specified equipment, which is deemed appropriate for the session. Such as hands on stomach or crystals on chakra points Yes

6. I am happy to provide any information in which the staff of Empowerment Healing deem necessary in order to provide the service I requested, including medical background, current ailments and medication taken.

I am happy to provide any information in which the staff of Empowerment Healing deem necessary in order to provide the service I requested, including medical background, current ailments and medication taken. Yes

7. The staff of Empowerment Healing have the right to cancel or discontinue any services at any time if they feel it is necessary to do so.

The staff of Empowerment Healing have the right to cancel or discontinue any services at any time if they feel it is necessary to do so. Yes

Confidentiality and privacy agreementExit this survey >>