Client Onboarding - Soul Resuscitation

This is more than a form it’s your starting point.

A space for you to get honest about where you are, what’s no longer working, and where you’re ready to go next.

The depth you provide here, shapes the work we do together.

Your Next Level Starts Here

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of Birth

Time of Birth

To the nearest hour if known

Previous History

Do you have any potentially life threatening conditions e.g heart trouble?

Do you have any current physical problems?

Do you have any allergies or other physical sensitivities?

If you answered yes to any of the above

Current Challenges

What is your goal for the session/s?

Terms and Conditions(Required)

Disclaimer: This is an agreement between the client and Leigh Clarke (the practitioner) concerning the Soul Resuscitation MAT Session(s) and upon submitting this agreement the client agrees to all terms laid out in this agreement.

By signing below I certify that I have read and understand this agreement and have full knowledge of its meaning and effect.

1. I authorise and request my practitioner to carry out MAT sessions. I understand the process of these sessions will be explained to me upon my request and that they are subject to my agreement. I also understand that while the course of my session is designed to be helpful, my practitioner can make no guarantees about the outcome of my session. Further, this process can bring up uncomfortable feelings and reactions such as anxiety, sadness and anger. I understand that this is a normal response to working through unresolved life experiences and that these reactions will be worked on between my practitioner and me.

2. I am at least 18 years old, the age of consent to make any decisions as to my person and treatment.

3. I understand that MAT sessions do not require physical contact or touch. I will remain fully clothed during my session and it is my choice if I want to be touched on my hand for comfort if I feel anxious or distressed. I understand that it is my choice if I want to hug the practitioner after a session.

4. It is my responsibility to notify the Practitioner of any current medical conditions and medications, allergies, recent surgeries, transplants, prosthesis, pacemaker or any other electrical, metal or magnetic item in my body. I understand that MAT is intended to help the client and any medical or psychiatric issue or condition that occurs during or after the MAT session is not the responsibility of the practitioner. In addition, the practitioner will not be held liable for any information withheld by me as to my medical or emotional conditions. I will not hold the practitioner responsible or seek compensation for any injury or illness suffered by me caused in whole or in part by my participation in this session.

5. Receiving a MAT session will not interfere or replace traditional medical or psychiatric care but can enhance other medical/psychiatric treatments. Therefore, clients under current medical or psychiatric care should not stop treatments or medication without advice of their physician/psychiatrist.

6. For maximum benefit, it is recommended that you do not consume any alcohol, caffeine, energy drink, nicotine or very spicy foods and practice moderation in exercise, work and temperature 12 hours prior and 12 hours after an Rapid Recharge MAT session.

7. Any communication via email or mobile phone may not be secure, so we will assume that you have made an informed decision when using these communication channels to provide information and are taking the risk of such communication being intercepted.

8. It may be necessary at times for us to leave or send you a message at the phone numbers and email addresses you provide. By supplying specific phone numbers and email addresses, you authorise me to leave messages for or send messages to you.

9. All information between practitioner and client is held strictly confidential. There are legal exceptions to this:
a. The client authorises a release of information with a signature.
b. The client presents as a physical danger to self or others.
c. Abuse and/or neglect are suspected.
d. The client is under criminal investigation and a subpoena by a court of law has been issued for information on the client.
In the case of #b or #c above, we are required by law to inform potential victims and legal authorities so that protective measures can be taken.

10. I understand that I am responsible for payment of all fees charged at the time of service to be paid either prior to or on the day of service. I agree to pay for all services rendered.

11. I am expected to arrive on time on agreed upon appointment date and time if it is a face to face session. If the session is online or phone, then I will be ready on time for my session and expected call from the MAT Facilitator. If I am 15 minutes or more late, then I will be charged for this time accordingly. Cancellations must be made at least 48 hours prior to appointment; otherwise I will be responsible for full cost of session. Should there be an emergency, no charge will be made, however, proof of said emergency will be required to void payment requirement.

12. Practitioner reserves the right to refuse any session without providing a reason and can cancel said session at any time. Any payment made prior to a session that is cancelled by the practitioner will be refunded in full.

13. I understand that my relationship with my practitioner is entirely professional and so any behaviour on my part that is not professional and can be deemed sexual or abusive will be reported to the appropriate authorities.

By checking the box on this form below, I confirm that I have read and understood the terms outlined above.

I freely and voluntarily give my consent to participate in the activity, program, or service described. I understand the responsibilities, requirements, and any potential risks involved.

I accept the terms and conditions of this agreement and agree to comply with all related rules and policies. I understand that I may withdraw my consent at any time by contacting the practitioner, recognising that doing so may affect my ability to continue with the related service or activity.

I confirm that I have read and understood the terms outlined above.

This should take around 10–15 minutes. Give yourself the space to do it properly.

The depth you provide here, shapes the work we do together.

Your Next Level Starts Here

Thank you!