Sound Healing & Sound Bath Consent
I am hereby requesting and consenting to Sound Healing services from Stefanie Summers at Deneki Wellness.
I understand that Stefanie uses a variety of instruments and her voice to create vibrational sounds to allow for a deep state of relaxation. This will help rejuvenate and restore the body’s own resonate frequencies in the physical, mental, emotional, and spiritual aspects so the energy of the body may come into harmony and balance. Everyone will have his or her own unique experience and each Sound Healing session may produce different results.
There are no officially recognized side effects from Sound Healing, and it is typically a safe procedure. However, sometimes this complimentary therapy can cause a healing reaction. Hence, following a session, you may feel symptoms intensifying before relief is achieved. This is not common, however, if a healing reaction does happen, you may contact Stefanie Summers to discuss this matter. If you feel the situation needs closer attention you should contact your physician.
STEFANIE SUMMERS’ QUALIFICATIONS
I am a Licensed Clinical Social Worker and a certified Reiki Master practitioner and Certified Level 1 Sound Healer and a Level 2 Sound Healer student at the Sound Healing Academy. I’m also certified as an Archangelic Light Practitioner and have completed a short-course series on the use of crystals.
You may find my complete résumé on Linked In at: linkedin.com/in/stefanie-summers-813a2217.
ACKNOWLEDGEMENT & CONSENT TO RECEIVE SERVICES
To utilize my services, please acknowledge receipt of the information provided within this form by signing it. I will keep the original on record for three (3) years.
- I have read and understand the above guidelines and disclosure about the Sound Healing/Sound Bath treatments and techniques offered by Stefanie Summers, as well as her training and education.
- I have been given ample opportunity to ask questions, and any questions have been answered to my satisfaction.
- I understand that crystals, reiki, and other forms of energy-based methods are not necessary for the Sound Healing experience, however, may be offered. I will tell Stefanie whether I wish to include them in my session or not.
- Should I experience any discomfort during the session(s), I agree to immediately inform Stefanie.
- I understand that Stefanie is not a Licensed Physician and that the alternative services that she will be providing to me are not licensed or governed by the State of North Carolina.
- I understand that it is my responsibility to maintain a relationship for myself and/or my child with a medical doctor and that should an adverse reaction occur, I will consult my doctor.
- I understand that Sound Healing/Sound Bath is not a substitute for psychotherapy, medical treatment, or medications. I am aware that Stefanie does not diagnose medical illness or disease, nor does she prescribe medications or recommend supplements. I understand that any suggestions that are provided to me should not be taken as a diagnosis or recommendation against the advice of a Licensed Physician or my own mental health counselor.
- I understand that Stefanie is also a Licensed Clinical Social Worker and that she provides psychotherapy services that are conducted SEPARATELY from the Sound Healing/Sound Bath experience she offers.
- I understand that if I am a client of Stefanie’s psychotherapy practice through Deneki Wellness, that Sound Healing/Sound Bath treatments may be used to enhance the therapeutic counseling services I receive from her and that Sound Healing/Sound Bath is not a substitute for psychotherapeutic counseling.
- I have consented to use the services offered by Stefanie Summers at Deneki Wellness and I agree to be personally responsible for her fees in connection with the services provided.
- If requested, I may receive a copy of this document.
- I fully understand the contents of this form, including the risks, contraindications, and benefits of Sound Healing through my OWN research of Sound Healing/Sound Bath.
- I am NOT pregnant/I AM pregnant. I have notified Stefanie if I AM pregnant via email. Should I become pregnant in the future, while seeking Sound Healing/Sound Bath, I will notify Stefanie so that she can adjust Sound Healing/Sound Bath treatment protocol, if needed.
- I do NOT have any implants/I HAVE implants. I have notified Stefanie if I HAVE implants via email. Should I receive implants in the future, I will notify Stefanie so that she can adjust Sound Healing/Sound Bath treatment protocol, if needed.
- I have NOT had any recent medical procedures with lingering complications. I HAVE notified Stefanie if I HAVE had recent procedures with lingering complications via email. Should I experience medical complications in the future, I will tell Stefanie so that she can adjust Sound Healing/Sound Bath treatment protocol, if needed.
- I am over the age of 18.
- I release Stefanie Summers/Deneki Wellness from any responsibility and/or liability that might arise from voluntarily participating in the Sound Healing/Sound Bath experience. By signing this consent form, you are acknowledging any risks that may be associated with your participation in the Sound Healing/Sound Bath experience.
BY SELECTING THE CHECKBOX I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
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