RELEASE AND CONFIDENTIALITY AGREEMENT

DIVINE JOURNEYS HEALING ARTS CENTER

I, _________________________________, enter into this Agreement with Karen Anderson of Divine Journeys Healing Arts Center to confirm in this Agreement the conditions of my participation in the reading to be performed by Karen Anderson. I have been made aware that the 90 minute session is Pre-Paid and the cost is $180.00 for one person (21-up) and $40.00 for each additional person. (Group sessions are 4 or less and share the 90 minutes in the session.) I have also been made aware that there is a $40.00 held back cancellation fee, if I cancel my appointment and do not reschedule within a two week period.

I acknowledge that I have voluntarily agreed to participate and have requested Karen Anderson of Divine Journeys Healing Arts Center to perform this reading. I acknowledge that Karen Anderson of Divine Journeys Healing Arts Center is not a Psychologist, Psychotherapist, Psychiatrist, Licensed Mental Health Counselor or Medical Doctor. I am aware that my participation in this reading is not a substitute for psychiatric treatment, psychotherapy, therapeutic counseling or any other form of professional therapy. 
 

I, _________________________________ am voluntarily participating in this reading and understand it is considered to be known as "Entertainment Purposes Only" and I accept complete responsibility for my own psychological, mental, emotional and spiritual well-being. I acknowledge that it is my responsibility to ascertain my own need for professional counseling and to seek such professional counseling, if needed.  I also understand that if any information is given during my reading that may pertain to medical and/or mental health, this is not a declaration of fact being made by Karen Anderson of Divine Journeys Healing Arts Center, but only a impression Karen is receiving at the given time.  I further acknowledge and understand that any information provided during this reading or any other statements made during same shall be considered confidential and shall not be disclosed except as required by law. 
 

I have carefully read this Agreement and fully understand it's contents, terms and significance and understand the legal consequences of signing this Agreement. I am aware that this Agreement contains a release of liability and a contract between myself and Karen Anderson of Divine Journeys Healing Arts Center and I sign this Agreement of my own free will. I also have been made aware that Karen Anderson of Divine Journeys Healing Arts Center will be tape recording this session for my own future referral to and are in agreeance with this procedure. 
 

 

Please print, sign, and fax to 866-486-0415 or

mail to Karen Anderson, PO Box 1112, Somis, CA 93066

 

Dated: ______________________

 Signed: ____________________________________________

 Email: _____________________________________________

Address:_________________________________________________________________________________

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