Forms

 

Required Disclosure under California Business & Professions Code §§ 2053.5-2053.6

and Informed Consent/Assumption of Risk

for the practice of Aiden Chase

 

 

By digitally signing this form below by checking the digital signature box and entering my name below, I the undersigned, understand and acknowledge all of the following:

 

1. Aiden Chase (“Consultant”) is not a licensed physician, and is not licensed by California or any other state as a healing arts practitioner.

2. The treatment offered by Consultant is alternative or complementary to healing arts services licensed by California.

3. The services to be provided by Consultant are not licensed by California or any other state.

4. The nature of the services Consultant will provide to me are as follows: “When someone comes to me for a energy healing and/or intuitive session, I look deep inside to reveal what the soul is asking for. These steps toward enlightenment are the genesis of healing.  The process I use is called the laying-on of hands or spiritual healing. Together we connect to the light healing force of love. Energy healing is a very straightforward process that involves the cleansing, rebalancing, and recalibrating of your energy field and body. In addition, I use many world energy healing techniques and modalities which may include energetic calibration, powerful and sacred rocks, minerals, crystals, touch, sound, aroma and music.”  -- Aiden Chase. 

5. The theory of treatment upon which the services are based is as follows: the services described in 4 above can help release blocks allowing energy to flow more freely in one’s life.

6. Consultant’s educational, training, experience, and other qualifications regarding the services to be provided are as follows: “I am a third-generation energy healer and intuitive. I have studied and continue to study energy healing theory and practice.”

 

In addition to the above disclosures, which are required by California Business & Professions Code § 2053.6, and which I have read, understood, and acknowledged, I also understand and acknowledge the following:

 

7.  I authorize Consultant to use physical contact and touch as necessary for the delivery of services described in 4 above.  

8.  I recognize that Consultant cannot guarantee results or any specific outcomes from our work together.  I am solely responsible for any action taken based on my interpretation of any information presented. 

9. I understand that Consultant has the right to refuse to continue delivering services at any time for any reason whatsoever. 

10. I am not engaging Consultant for any medical or psychological services.  I understand that Consultant does not diagnose or treat any medical or psychological condition, and that Consultant’s services are not designed to replace conventional treatment methods of medical or psychological conditions. I am aware that health care decision-making, both physical and mental, begins with my obtaining a complete medical evaluation by my primary care health provider including current health practices in order to develop a therapeutic treatment plan which enhances my health promotion and maintenance, reduces opportunity for untoward side effects or contraindications, and safeguards my health.  I am aware that mental health care issues require care by an appropriately licensed health care professional such as a licensed psychologist, and that Consultant is not licensed by California or any other state as a psychologist and is not delivering psychological services. I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals. 

11. I understand that working with Consultant may bring up distressing feelings, images, thoughts and behaviors. Some of these distressing experiences may persist or resurface at a later time. I agree to seek medical assistance or psychotherapy or any other appropriate physical or mental diagnosis and treatment from a practitioner duly licensed in California (such as a licensed medical doctor or licensed psychologist) and/or my respective state if I find that these distressing aspects create a danger for myself or for others.

12. I knowingly, voluntarily, and intelligently decide to receive the services described in 4 above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, indemnify, and defend Consultant and his agents from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described in 4 above, or arising out of or in connection with referral to other practitioners or merchants for delivery of any services.

 

I have carefully read this form and acknowledge that I understand it. I also acknowledge that I have been provided with a copy of this form by my printing out a copy of this form before I submit it.  No representations or statements, oral or written, have been made to me, apart from those described in this form. This form will be interpreted under California law, and California will be the forum for any claims filed under or incident to this form.  If any portion of this form is held invalid, the rest of the document will continue in full force and effect.  

* Required fields
Name *
E-mail Address *


Please enter the code shown above and click the 'Submit Form' button. This additional step is required to help protect against message spam.