Name:
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First Name
Last Name
What name do you prefer to be called?
What pronouns do you use?
Email
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Age:
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Birth Date:
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MM
DD
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Phone Number:
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(###)
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Address:
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Do I have your permission to stay in contact through emails and promotions?
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How did you specifically hear about our retreat or Condor Medicine coaching?
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Briefly describe your intention for working together and/or what you are hoping to work through:
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Have you been under treatment of a physician (physical or psychological) in the past, especially this past year)? Have you ever been diagnosed with a psychiatric or psychological condition?
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If so, please describe, and provide the name of the physician and phone number:
Have you ever been hospitalized for any psychiatric issues?
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If so, briefly describe the circumstances:
Are you now or have you ever been suicidal?
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Are you currently taking any pharmaceutical or over the counter drugs?
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If so, what are you taking and why?
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Do you take any illegal drugs? If so, what and how often?
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Have you ever been treated for an emotional problem?
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Can you explain the circumstances?
Have you ever been worked with shamanic practices, ceremonies or energy work?
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If so, please briefly tell me about your experience:
Do you have any other medical issues or health concerns I should know about?
How would you describe your diet and eating practices?
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What do you do to relax?
Do you consider yourself a spiritual person? If yes, what are some of the practices you participate in, if any?
If no, do you identify as atheist, agnostic, non-dual, etc.?
Do you meditate?
Do you exercise?
How often/what form of exercise do you practice?
Is there any other information you feel is important to share before our first session?
I swear that I have answered all of the above questions truthfully to the best of my ability
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I Hereby Consent:
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Shamanic Hypnotherapy and Coaching Private Session Release of Liability Agreement “I take full responsibility for my experience” “I am free to leave at any time during a session” I, the undersigned, have registered for a Private Session with by Condor Medicine LLC.
1. I hereby agree in this release of liability agreement (the “Release”) in favor of each of the Releasees herein) as follows:
2. For the Session or Sessions, I may need to provide personally-identifying information including my name, email address, phone number, address, or billing information, and by providing such information I grant permission to Condor Medicine LLC to use and store it as needed, subject to best efforts to keep such information secure and confidential.
3. The Session uses tools based in neuroscience such as new learning experiences, healing sentences, hypnotherapy techniques, visualization, and occasional light physical contact (if the session is in-person) intended to foster awareness of body sensations, each offering an opportunity to develop new insights (together, the “Exercises”).
4. I hereby consent to the Exercises and acknowledge that I am free to withdraw my consent or leave at any time. I understand that traumatic events will likely be discussed in the Session, and participating in the Session may bring up highly personal issues that may cause me to experience some temporary stress or unexpected responses of a physical, psychological, mental, emotional, or spiritual nature. I understand that there is a risk of accident, injury, and emotional distress from my participation. I agree to take full responsibility for, and expressly assume all risks of my participation in the Session, and I hereby agree to fully and completely hold harmless, indemnify and irrevocably release each of: (a) Colette Schmitt, Condor Medicine LLC, and each of their respective officers, agents, employees, trainers or contractors; and (b) each of their respective heirs, successors, and assigns (collectively, the “Releasees”), from all liability for any illness, injury, stress, or condition (physical or mental) or other loss or damage of any type whatsoever, in law or in equity, that may occur at any time in connection with the Session, even if arising from negligence, to the fullest extent permitted by law (and I waive any claim or liability with respect to the Releasees of any nature in relation thereto). I agree that I will not hold any Releasee liable for any information received or results experienced in connection with the Session.
5. I hereby represent and warrant that I do not currently suffer from and that I have not been diagnosed with, any illness, disorder, or condition, either physical or mental, that may make it unadvisable, for any reason, for me to either participate in the Session or to assume all risks of the Session. I acknowledge that the Session provides information only, and does not diagnose or treat any condition (either for me or anyone else). I understand that although this Session may be therapeutic in effect or intent, it does not take the place of the care of a doctor, psychologist, or other healthcare providers of any type. Information provided during the Session is educational in nature only, and is intended to help me become more conscious of my own mental and physical health processes, and should be employed at my own discretion. I understand that I am solely responsible for the results of the Session. I understand that each Releasee is not a psychologist and that the Session is not a substitute for conventional therapy or any other professional consultation.
6. This Release shall be governed by and interpreted in accordance with the laws of the State of Pennsylvania, without regard to the choice of law provisions. I hereby agree that in the event that any clause or provision of this Release is deemed invalid, ineffective, or unenforceable, the enforceability of the remaining provisions of this Release shall not be affected. This Release contains our entire agreement. I have read and confirm that I understand this Release, and by my signature below I agree to all terms thereof.
eSignature:
Date:
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MM
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Email:
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