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Client Intake Form Self Paced

Welcome:

This form allows your student practitioner to get to know a little more about you, why you are seeking a session and for you to understand what a session entails. Please answer the questions below to the best of your ability. There are no wrong answers and you can give as much or as little detail as feels comfortable. We appreciate answers to this form in English.

Before completing this form, please ensure you familiarise yourself with the Scope of Practice that your Student Tantra Practitioner is trained, competent and authorised to practice (as defined by the Embodied Awakening Academy). You can read it HERE. If you have any questions around this information, please do not hesitate to ask your student practitioner or email the Embodied Awakening Academy via [email protected].

Client Information

Practitioner Information

Prior Medical Conditions:

Please ensure you read the information about potential contraindications of this practice HERE before filling out the Prior Medical Conditions section.

Please Note (from your practitioner):

As a Student Tantra Practitioner, I am here to support you in your embodied awakening. I am not to be relied on in place of your current health care professional or medical doctor and do not advise you to discontinue any medical treatment you may be receiving. My work is intended to be in harmony with any other healing work that you undertake, including traditional medicine.

Client Responsibility and Waiver*

I (the client) verify that all information, provided on this form, is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential unless I provide written consent.

I agree to provide full disclosure of my current medical situation, including but not limited to all relevant treatments and medications and that any changes occurring during our sessions, are required to be communicated to my practitioner. I understand that the services offered in these sessions are not a substitute for medical care.

I hereby give my consent to receive treatments and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such services are my sole responsibility.

I understand that the session will be facilitated by a student Practitioner of Tantra and that as such the student is not yet as proficient, experienced, or trained in all of the techniques and protocols that a certified practitioner would be expected to know. However, they are equipped with the tools to hold me through deep, embodied transformation with loving presence.

If I experience pain or physical discomfort during the session, or if I am uncomfortable with any part of the session, I will immediately inform the student Practitioner.

My decision to receive services is voluntary, and I know of, understand and assume any and all the risks associated therewith. On choosing to engage in sessions I assume personal responsibility to manage my current physical, emotional or mental health conditions.

By clicking the submit button below, I acknowledge I have read and agree to the above waiver and conditions and I hereby waive and release my Practitioner and the Embodied Awakening Academy from any and all liability, past, present and future relating to this session work.

In addition, as part of the exchange of this session, I agree to complete the Client Feedback Form, in order to support the student practitioner to complete their training.

If I have any questions or concerns, I will inform the student practitioner and/or the Embodied Awakening Academy via [email protected].

“Thank you for submitting this form. Your information has been received and your Practitioner will follow up with you directly, if necessary.”