As a Hibiscus Moon Certified Crystal Healer, I would like to welcome you to my practice and provide some information relevant to our relationship and your experience during the energy healing process. Along with all other information you receive from me during your initial intake, please read this information carefully, as both myself as healer and you as client must sign this disclosure before we begin.  Although not required, I will attempt to keep a copy of this disclosure and all other paperwork in my records for up to three years.

 

Crystal Treatment

The purpose of a crystal healing session is for mental and spiritual well-being.  My method of treatment – energy healing – is an alternative or compliment to healing arts otherwise licensed by the State.  We will use a variety of techniques to facilitate well-being and clarity in the moment, while promoting long term self-reliance through practical techniques to help raise consciousness, clear confusion, recognize intent, interpret meaning and quell doubt.  

 

If you ever have any concerns about the nature of your treatment, you are free to discuss them with me at any time.  As I am committed to monitoring your progress, I ask that you please bring any new information affecting your treatment as soon as practical.  You are entitled to stop treatments at any time, with or without reason, and I recommend that you inform your medical doctor that you are receiving energy healing treatment.  While I will use my best efforts during our sessions, I cannot guarantee any particular outcome as results vary from person to person.

 

State and Federal Law

I am not a licensed physician, nor are energy healing services licensed or controlled in most states.  As your healer, I am responsible for knowing any applicable State and/or Federal laws that may apply to me, and for disclosing those laws to you. Since it is likely that any laws regarding crystal healing will change over time, I also encourage you to research and stay informed on current laws and to bring any changes to my attention.

 

Requirements to be a Hibiscus Moon Certified Crystal Healer

In addition to my commitment to a professional Code of Ethics, I completed a sequence of classes through the Certification Program and achieved a passing average grade of 75% or higher on the required corresponding assignments.  Further, I was required to perform healing sessions reviewed by my instructor and clients for effectiveness and professionalism, and otherwise encouraged to continue hands-on training in my practice.  I received an Official Certificate of Completion to be qualified to use the letters CCH after my name and earned 18 Continuing Education Units with the National Certification Board for Therapeutic Massage & Bodywork.  If you have not already done so, you may request to see my Certificate at any time or a current list of my other qualifications.

 

I was certified by Hibiscus Moon on May 16, 2019. 

* Please see www.HibiscusMoonCrystalAcademy.com for more information on the certification process and requirements, or to confirm my certification through the program.

 

 

Healer’s Qualifications

In addition to my certification, as well as continuing efforts to educate myself on the techniques used in my practice, my other qualifications include: 

Certified Crystal Reiki Master/Teacher

Certified Hypnotherapist

Certified Clinical Aromatherapist 

Ordained Metaphysical Minister

 

Healer’s Commitments to You:

As a Healer, part of my certification process through the Hibiscus Moon Certification Process included commitment to a Code of Ethics that requires professionalism, safety, and consistency in all healing practices.  Thus, in my practice of the Hibiscus Moon Crystal Healing Method, and as a Certified Crystal Healer, I have vowed to always:

 

  1. Practice methods as taught during my Certification and use all precautionary measures; 

  2. Only perform massage, acupuncture, or acupressure if licensed to do so;

  3. Preserve client confidentiality, and never share information learned during sessions with others or intake unless required by law;

  4. Abstain from giving any medical diagnoses, interfering with the treatment of a licensed health care provider, or suggesting the use or change of use of any prescription, medication, or treatment;

  5. Actively work on my own healing and education so as to embody and fully express the essence of Crystal Healing in every facet of my life;

  6. Be responsible for the energy I bring into the healing space and into any transactions as a student or as a healer, always striving to be positive;

  7. Never attempt to awaken Kundalini on others;

  8. Be open to the continuing process of enhancing my professional qualifications, training, experience and skills;

  9. Respect and value all energy workers and types of healing modalities, and refrain from making negative statements about others;

  10. Encourage my clients to heal themselves, and assist them in their personal growth as well as their own crystal practice;

  11. Treat my clients and their physical person with the greatest respect, and never engage in any illegal or immoral activity which hurts them, such as unsolicited touching of their genital area or breasts, asking them to disrobe, or sexual comments, jokes or references;

  12. Abstain from the use of drugs or alcohol during all professional activities;

  13. Be truthful in my advertising by openly discussing my training and background, what is offered in a crystal healing session, the fee that is charged, and the amount of time spent in sessions; 

  14. Educate my clients regarding the merit of crystal healing in conjunction with other medical treatments, and thoroughly explain that it does not guarantee a cure and is not a substitute for medical or psychological treatment, but only a supplement to these treatments. 

  15. Learn and obey the most current local, state, and federal laws applicable to my practice.

 

Governing Law/Venue

This Disclosure is governed by and to be construed in accordance with the laws of the United States and the State of Georgia,and any claim, action, or suit that arises out of or relates to performance of healing services shall be brought and conducted solely and exclusively within the State of Georgia,venue being proper in whatever county the primary office providing healing services is located.  

 

 

 

Healer Commitment in Providing Services 

The Disclosures made here are accurate to the best of my knowledge and reflect my commitment to your healing as my client. I will at all times endeavor to abide by the Code of Ethics I have adopted for myself.  I will work with you in your energy healing to reach the goals you have set for yourself and will not interfere with your own personal beliefs or energy efforts.  If at any time I feel it necessary or advisable, I will discontinue our healing sessions to prevent any harm to you, to myself as healer, or to my healing practice. I have made these disclosures voluntarily and, while I make no representations that the information contained herein will remain accurate during the duration of our healer-client relationship, I will work within the terms of this disclosure as far as I am able.

Innocence Smith 

Healer. Mentor. Teacher    

 

Client Acknowledgment and Consent to Receive Services: 

I have read and understand the above Disclosure about the energy healing treatment offered and have discussed with my healer the nature of the services to be provided.  I consent to and affirm all the terms included in this Disclosure, and agree to read all material provided to me regarding my healer’s practice. I understand my healer is not a licensed physician and that energy healing services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself with a medical doctor. I have consented to use the services offered, and agree to be personally responsible for all fees charged in connection with the services provided to me.

 

 

Consent and Release of Liability 

By typing your signature and hitting the Submit Button, you are agreeing to each line below:

____ I am requesting the service of Innocence Smith, CCHa healer, for the purpose of assisting me to access my own inner resources of healing energy so that I may learn to heal myself.

____ All information I have provided in this Intake and Consent Form is accurate to the best of my knowledge

____ I understand no guarantees or warranties are made to the effectiveness of crystal healing, and take full responsibility for my expectations of the healing process.

____ I have been explained and understand the associated risks with my practice of crystal healing, if any, and agree that it is my responsibility to seek any further information I feel I need.

I ____ did ____ did not provide medical information in this form, and ____will ____ will not be giving permission to share this information with third parties.

____ I have been given the opportunity to read my healer’s HIPAA privacy policy, and have read (or waived my right to read) and understand its contents.

____ I understand that, while certain medical options may be explained to me in the course of my healing, these explanations are in no way either a suggestion for medical treatment or any sort of prescription or medical directive, and do not constitute licensed medical advice.  I waive any and all remedies I may have based on my own reliance on such information.

____ My healer signed a Client Disclosure Form in my presence such that I understand its contents and I accept its terms, without condition.

____ I agree to pay my healer directly by CashApp(method), at the time of service for any traveling fees at a rate of $25/hr.

____ I agree to pay, whether or not my healer has forgiven or waived a charge in the past, all the following non-refundable fees, without exception:

 

 

 

            $90 Appointments lasting 60 minutes.

            $125 Appointments lasting 90 minutes.

            $160 Appointments lasting 120 minutes.

            $50/hr.All other appointments.

            $45 Late Cancellation (less than 24 hours before appointment time).

            $50 Bounced checks.

            $45/Per late payment, if/when accepted.

____ I release my healer, as well as any of his/her assistants or related business interests, from any and all liabilities or claims of any nature that may result my participation in crystal healing, including but not limited to damages from my failure to pursue medical attention from a medical professional, for the exacerbation of any preexisting physical ailments I may have, and By signing below, I agree to all these terms, and further bind my estate, heirs, and assigned to this release of liability. 

                                  

 

  

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