FORMS

1. Select the form for your scheduled service.

2. Complete the form before your scheduled appointment.

First name

Last name

Birthday

Month

Day

Year

Date of Completion

Occupation

Service Requested

Emergency Contact Information

Please list any current medications, supplements or any other health concerns we should know about?

Any Allergies

Have you ever had the service you are requesting? If yes, please describe any issues you had after.

What is your primary intention for this session?

Any additional information you would like to share?

I understand that preparing for my session may require fasting, hydration, or avoiding certain foods and substances. I understand that after my session, I may experience emotional, energetic, or physical detox symptoms and will be provided integration.

Agree

Disagree

I understand that my selected services can potentially assist my body in healing and is done with little/no physical contact. I know that long term dis-ease in my body may require multiple sessions to facilitate the level of relaxation needed to heal.

Agree

Disagree

I understand that the selected service is not intended to replace any currently prescribed medical treatments as ordered by my physicians, nor any other medical care I have, or may be advised to seek by them.

Agree

Disagree

I understand that the practitioner will not diagnose nor prescribe for any condition that I might have. Nor does that practitioner make any specific claims regarding results from sessions I receive.

Agree

Disagree

I agree that it is my responsibility to consult a licensed medical practitioner for any physical or mental complaints I may have.

Agree

Disagree

I understand that all client information and records are treated in a confidential manner. My experiences during these sessions are confidential subject to the usual exceptions governed by state or federal laws and regulations.

Agree

Disagree

I, or my representative(s) agree to fully release and hold harmless Qwantum Alchemy and practitioners therein from and against any and all claims or liability of whatsoever kind or nature arising out of, or in connection with, my session (s).

Agree

Disagree

By signing below I give my consent to receive treatment and agree to all the terms and conditions provided above.

Signature field is empty.

Intake and Consent Form

Client Contract

By signing this agreement, you acknowledge that you are voluntarily participating in one or more of the following services offered by Qwantum Alchemy:

Reiki Energy Healing (chakra balancing, trauma release, emotional clearing)
Sound Healing Therapy (vibrational therapy, tuning forks, singing bowls)
Kambo Detox Ceremony (sacred Amazonian frog medicine for deep cleansing)
Hapé & Sananga Ceremony (sacred plant medicine for grounding and spiritual clarity)
Light Language Activation (energetic attunement and DNA activation)
Kundalini Energy Activation (awakening and realignment of life force energy)
Women’s Wellness Rituals (cacao ceremonies, feminine energy healing)
1:1 Spiritual Mentorship & Coaching (personalized guidance for healing and transformation)

Client Acknowledgment & Health Disclosure:

I acknowledge that the services provided are not a substitute for medical or psychological treatment. I understand that these holistic healing practices are complementary therapies and should not replace medical care.

Medical Conditions & Contraindications:

I confirm that I do not have any of the following conditions that may prevent me from safely receiving certain services:

Heart conditions, blood clots, low blood pressure, or history of stroke (for Kambo & Hapé)
Severe mental health disorders (e.g., schizophrenia, psychosis, bipolar disorder in an active phase)
Pregnancy or breastfeeding (for Kambo, Hapé, and certain energetic activations)
Use of antidepressants, SSRIs, or certain medications that contraindicate Kambo
Glaucoma or recent eye surgery (for Sananga)

I take full responsibility for informing the practitioner of any health conditions, medications, or concerns that may affect my ability to safely participate.

Informed Consent & Release of Liability

I understand that:

The results of energy healing, plant medicine, and spiritual activations vary from person to person.
Temporary emotional, energetic, or physical detox symptoms may occur after sessions.
I will follow all pre-treatment and post-treatment instructions provided to ensure my safety and maximize healing benefits.
I am solely responsible for my well-being during and after my session.
The practitioner is not liable for any adverse reactions, personal decisions, or experiences following the session.

By signing below, I confirm that I have read, understood, and agree to this contract.

I