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* 1. Name

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* 2. Cell Phone

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* 4. Identity and Ability to Give Consent:

I certify that I:
a) am of legal age
b) am free of mind-altering substances at time of session and will remain so during session
c) have disclosed physical or psychological conditions or diagnoses that may be relevant to a session or my ability to legally give consent
d) have accurately and completely divulged pertinent criminal background information, including any history of sexual assault, or other violent crime, if asked to.

Safety and Comfort:

I understand that Maryam R. Brown dbs Mia Maldonado may decline to provide or terminate a session at her sole discretion and for any reason, including but not limited to reasons of comfort or safety, at any time. I, as the client, may also terminate a session at any time at my sole discretion. No refund or partial refund shall be given by Touch Positive LLC in the event of an early termination of session. I understand that for security reasons, my name, address and contact information may be made available to a trusted 3rd party who will access the information if necessary.

Social Media & Confidentiality:

I understand that Maryam R. Brown / Mia Maldonado does not accept friend requests or public contact from clients on her personal Facebook profile (you are encouraged to connect with Touch Positive business social media pages). Mutual respect of privacy and the confidentiality of our personal information are extremely important. We can establish warmth and friendliness, but we cannot become personally involved outside of the therapy setting.

Voluntary Participation; Respect for Boundaries:

I agree that:
(a) my attendance at this session is voluntary and for my personal enrichment only
(b) I will not engage in any non-consensual touching, badgering or intimidation of any kind
(c) I will comply with any and all federal, city, state or county laws, statutes or regulations during my session
d) I understand it is my responsibility to know and communicate my general state of health and any conditions or special limitations that may affect my session.

Platonic Services:

No sexual activity will be permitted. I understand that, although intimate, sessions are strictly platonic and non-sexual. I understand that sexual arousal may occur and Practitioner and Client both agree to neither shame nor pursue arousal.

INITIAL BELOW

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* 5. Indemnification & Waiver of Liability:

I hereby agree to release, waive, hold harmless, and indemnify Touch Positive LLC / Maryam R. Brown dba. Mia Maldonado from any and all claims, loss, liability, costs, or damages to personal or physical property, of any nature, whether known or unknown, in law or in equity, which may arise in, from, or related to the course of any session, workshop, or any other services provided to me.

Assumption of Risk:

I assume full responsibility for any risk of bodily injury, illness, psychological or emotional harm, death, or property damage, to myself or others, arising from my attendance or participation in this session and any additional sessions or any other services provided to me by Maryam R. Brown, whether caused by any participant in the session or otherwise. Without limiting the foregoing, I acknowledge and understand that this session may explore new emotional concepts and may involve situations in which I feel uncomfortable, and willingly assume that risk.

I HAVE READ AND FULLY UNDERSTOOD THIS RELEASE AND WAIVER OF LIABILITY, AGREE TO AND/OR ACKNOWLEDGE THE TERMS, REPRESENTATIONS, AND INFORMATION SET FORTH ABOVE, AND FREELY AND VOLUNTARILY ELECTRONICALLY SIGN BELOW. I UNDERSTAND THAT BY SIGNING BELOW, I MAY BE GIVING UP SUBSTANTIAL RIGHTS AND I INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

I AGREE THAT THIS ELECTRONIC SIGNATURE SHALL FUNCTION AS MY LEGALLY BINDING SIGNATURE

FULL LEGAL NAME BELOW

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