Remote Healing Session Form

Thank you for requesting a remote healing session with William. He looks forward to working with you soon in your session. Before your scheduled healing session, please take a moment to fill out the New Client Information Form on this page. Please fill in all appropriate information below and click "submit." Your information is kept strictly confidential and is never shared with anyone other than your therapist.

Thank you!

 

Session Notes

Once you have completed the New Client Session Form, William will contact you to schedule a time for your remote healing session, if a time has not yet been set. Remote Healing Sessions last 30 minutes and it is not necessary for you to be in contact with William during your appointment. However, please plan to find a quiet place in which you may rest and observe your responses during your session. Following your appointment, William will be in contact with you via email to report his observations and the work that he completed.

Thank you!

 

 

Because you are working with William for your healing, please list current health conditions and/or pain issues you would like us to address in the field below.

 

 

Are you under the care of a qualified medical physician?

 

Have you ever seen a Holistic Therapist before?

 

How did you find William?

 

PLEASE READ: I understand that the healing therapy given to me is not a substitute for medical or psychological diagnosis or treatment. I understand that absolutely no one affiliated with Xen Healing Arts, LLC, makes any guarantee that I will receive healing of my disease or conditions. I also understand that William does not diagnose conditions, nor does he prescribe or perform medical treatment, nor prescribe substances, nor interfere with the treatment of a licensed physician or licensed health care professional for any physical or psychological ailment I have. It is recommended that I see a licensed physician or appropriate professional for any physical or psychological ailment that I may have. I understand that this therapy can complement any medical or psychological care I may be receiving and I affirm that well-rounded care, including holistic methods, is important to me.

Energy healing causes no harm, therefore, I shall not hold Xen Healing Arts LLC, William Barnett, or any practitioners working at Xen Healing Arts liable or responsible in any way for my health condition, past, present, or future. I consent to the application of the bio-energetic holistic modalities presented to me, understanding that I may refuse treatment at any time. By signing this agreement, I release Xen Healing Arts LLC, William Barnett, and anyone associated with Xen Healing Arts LLC from liability.

I understand that if treatment is for a minor child (under 18), a parent or guardian must approve of this therapy for the minor involved.

 

PAYMENT FOR THERAPY - Payment for therapy is expected by the time of service. We accept Credit Card, Debit Card, Cash, and Personal Check.

PRIVACY NOTICE: No information about any client will be discussed or shared with any third party without written permission of the client or the parent/guardian if the client is under age 18.

I have read and understand the policies and privacy notice above (please indicate below).