CLIENT INFORMATION

Full Name: __________________________________________

Date of Birth: _______________________________________

Phone Number: ______________________________________

Email Address: ______________________________________

Emergency Contact Name & Phone: _______________________

HEALTH & WELLNESS HISTORY

Please check and/or explain any that apply:

☐ High Blood Pressure
☐ Heart Condition
☐ Respiratory Conditions (Asthma, etc.)
☐ Skin Conditions (Eczema, Psoriasis, etc.)
☐ Chronic Illness
☐ Pregnancy or Trying to Conceive
☐ Recent Surgery or Injury
☐ Allergies (Herbs, Oils, Products): ____________________
☐ Current Medications: ________________________________

Additional Notes: ____________________________________

SERVICES REQUESTED (CHECK ALL THAT APPLY)

☐ Reiki Energy Healing
☐ Massage Therapy (Student Training)
☐ Tarot Reading / Spiritual Guidance
☐ Halotherapy (Salt Therapy)
☐ Yoni Steam / Womb Wellness
☐ Sound & Vibration Therapy
☐ Wellness Coaching
☐ Nutrition Coaching
☐ Life Insurance & Financial Education
☐ Wellness Products

ACKNOWLEDGMENT OF HOLISTIC SERVICES

I understand that all services provided by Wholistically Yours LLC are holistic in nature and are intended to support:

• Relaxation
• Stress reduction
• Personal growth
• Spiritual insight
• Overall wellness

MEDICAL DISCLAIMER

I understand that:

• Services provided are not medical diagnosis or treatment
• No prescriptions or medical interventions are being given
• I am responsible for maintaining care with my licensed healthcare provider

Even though services may be provided by a Registered Nurse, I acknowledge that this is not a clinical medical visit.

MASSAGE THERAPY CONSENT (STUDENT STATUS)

I understand that massage services are provided as part of training as an Aspiring Myomassologist.

• Services are for educational and practice purposes
• Techniques and pressure may vary
• No guaranteed therapeutic outcomes

REIKI & ENERGY HEALING CONSENT

I understand that Reiki and energy healing:

• May involve light touch or no touch
• Support energetic balance and relaxation
• May result in emotional or physical responses

TAROT & SPIRITUAL SERVICES DISCLAIMER

I understand that tarot readings and spiritual guidance:

• Are for insight and reflection
• Are not predictive guarantees
• Do not replace legal, medical, or financial advice

All decisions made are my own responsibility.

HALOTHERAPY CONSENT

I understand that halotherapy:

• Is a natural wellness practice
• May support respiratory, skin health and relaxation
• Is not a medical treatment

I confirm I have disclosed any relevant conditions.

YONI STEAM / WOMB WELLNESS CONSENT

I understand that:

• Yoni steaming is a traditional holistic practice
• It is not suitable during pregnancy or menstruation
• I must disclose all relevant health conditions

I accept full responsibility for participation.

WELLNESS & NUTRITION COACHING CONSENT

I understand that wellness and nutrition coaching:

• Provides general guidance on lifestyle and nutrition
• Is not medical nutrition therapy
• Does not replace a physician or registered dietitian

I acknowledge that:

• Results are not guaranteed
• I am responsible for my own health decisions
• I should consult a healthcare provider before major changes

LIFE INSURANCE & FINANCIAL SERVICES DISCLAIMER

I understand that:

• Information provided is educational
• All financial decisions are voluntary
• I am responsible for reviewing policy details before enrolling

ALLERGIES & RESPONSIBILITY

I confirm that I have disclosed all relevant:

• Medical conditions
• Allergies
• Sensitivities

I understand that failure to disclose may increase risk and release the practitioner from liability.

LIABILITY WAIVER

I voluntarily accept all services and release:

Wholistically Yours LLC and Tatiana RN

from any liability related to:

• Injury or discomfort
• Allergic reactions
• Outcomes of services
• Decisions made based on guidance

PHOTO & MEDIA CONSENT (OPTIONAL)

☐ I consent to photos/videos for promotional use
☐ I do NOT consent

CLIENT AGREEMENT

By signing below, I confirm that:

• I have read and fully understand this form
• I have had the opportunity to ask questions
• I voluntarily agree to all terms

Client Signature: __________________________________

Date: ____________________________________________

Practitioner Signature:
Tatiana RN
Wholistically Yours LLC