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FORMS

New Client Consent Form

I, the undersigned client, hereby consent to receive some or all of the following services from Merkaba Center for Healing, LLC, and Kendra Bratherton:


  • Energy & Vibrational Work

  • Mind-body Dialogue

  • Intuitional Guidance

  • Somatic Awareness

  • Spirit/Soul Guidance

  • Ancestral Repair Facilitation

  • Quantum Consciousness Facilitation


I understand that the services provided are considered complementary to standard medical care and are not intended to replace it. I acknowledge that I have read and understood the following disclaimer:


Disclaimer:

I acknowledge that the services provided by Merkaba Center for Healing, LLC, and Kendra Bratherton are not a substitute for professional medical treatment or advice. I understand that any information, guidance, or techniques offered are not meant to diagnose, treat, or cure any medical condition. I hereby waive Merkaba Center for Healing, LLC, and Kendra Bratherton of any, and all liability, now and in the future, for any damage, complications, or issues that may arise from or be connected to any services rendered or not rendered.

I am aware that Merkaba Center for Healing, LLC, and Kendra Bratherton have General Liability Insurance through ABMP (Associated Bodywork and Massage Professionals). Kendra is also an Ordained Minister.


I understand that all information I share during sessions will be kept confidential under ethical guidelines, except for legal requirements such as harm to oneself or others, reported child abuse, homicide, suicidal intent, or as required by court action.


I acknowledge that the practitioner reserves the right to decline services or stop a service at any time. I understand that if service has started no reimbursement of funds shall be granted. The practitioner reserves the right to stop a session due to any sexually inappropriate innuendos, touch, or looks.

By signing below, I acknowledge that I have read and understood the contents of this consent form and disclaimer. I voluntarily consent to the services provided by Merkaba Center for Healing, LLC, and Kendra Bratherton.

Nervous System Form

Chronic Physical Tension

Mark each box that you are experiencing.

Multi choice

Rate severity from this section, 1-10 (10 being constant and debilitating).

Mental/Emotional

Multi choice

Rate severity from this section, 1-10 (10 being constant and debilitating).

Heart/ Lung Issues

Multi choice

Rate severity from this section, 1-10 (10 being constant and debilitating).

Visceral Organ Dysfunction

Multi choice

Rate severity from this section, 1-10 (10 being constant and debilitating).

Immune System problems

Multi choice

Rate severity from this section, 1-10 (10 being constant and debilitating).

Behavioral Problems

Multi choice

Rate severity from this section, 1-10 (10 being constant and debilitating).

Interpersonal relationships 

Multi choice

Rate severity from this section, 1-10 (10 being constant and debilitating).

Other Problems

Multi choice

Rate severity from this section, 1-10 (10 being constant and debilitating).

Follow-up Reflection Form

Date
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