top of page

New Client Form:Waiver,Consent, & Privacy
Please complete a form for each individual of your family, if applicable.

Have you had an Emotion Code, Body Code, or Belief Code Session?
Have had a Reiki Session Before?

Terms and Conditions of Emotion Code, Body Code, Belief Code, Reiki, and any other Energy Session requested by the client:

​

1. I understand that Rene Bandy with, Mindful Balance with Rene LLC,  (herein referred to as "Practitioner") does not practice Physical medicine, Nursing, Behavioral health; is not a Marriage & Family counselor, Psychologist, or Psychiatrist.

​

2. I understand that if I have a physical or mental health emergency, I will contact the appropriate licensed medical professional or call 9-1-1.

​

3. I understand that if my practitioner makes any suggestions regarding supplementation of any kind, such as vitamins, minerals, herbal preparations, or any compounds or any other external remedy of any kind, that I use or ingest any such at my own risk, with the recommendation that I seek the advice of a physician before using any remedy suggested by my practitioner. I will not hold the practitioner liable if I choose to ignore my physician's advice.

​

4. I understand that in any of the sessions mentioned, the release of trapped emotion(s) or other energy(s) may result in “processing” where echoes of the emotion(s) or other energy(s) released may manifest in temporary physical or emotional discomfort, and that this “processing” appears to be a normal part of regaining energetic balance. If experienced, the symptom(s) can potential last for several days and vary from client to client.  The client will ensure they have in place the appropriate mental, physical, or other support the client may need while they are processing.

5. I understand that releasing trapped emotions, or the correction of any other energetic imbalance using these any of the  methods practiced by the practitioner listed is not a substitute for medical care. This information is not intended as medical advice and should not be used for medical diagnosis or treatment. Information received is not intended to create any physician-patient relationship, nor should it be considered a replacement for consultation with a healthcare provider, nor is it meant to replace any medical treatments as ordered by any physicians nor any other medical care you have been advised to seek by them. I further understand that these methods are not a replacement for any professional psycho-therapeutic or counseling sessions in the treatment of any mental health issues or disorders.

 

6. I understand that Reiki is a simple, gentle, with occasional hands-on energy, with permission from the client and  while fully clothed.  Reiki is technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions, nor do they prescribe or perform medical treatments, prescribe substances, nor interfere with the treatment of a licensed medical professional.

 

7.I understand that the methods, including but not limited to Reiki and other energy work requested by the client does not take the place of medical care. It is recommended that I see a licensed physician or a licensed health care professional for any physical or psychological ailment I may have. 

8.  I understand that my practitioner makes no claims as to healing or recovery from any illness I may have now, nor the prevention of any illness I may have in the future and that no guarantee is made towards validity. I further understand that the use of any information I receive is at my own risk.

9. I understand that if I have health concerns, I am recommended to seek advice from an appropriate medical practitioner before making any decisions about my health, or taking any supplements the body identifies and that this information is offered as a service and is not meant to replace any medical treatment.

10. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Rene Bandy of Mindful Balance with Rene from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

11.  I understand that my client report will be emailed within 24 hours of the session.

​

12.  I understand that I will defend , indemnify, and hold harmless the practitioner and it's affiliates, if the client causes harm to themself or to someone else.     

​

13.  I understand that the Practitioner, has the right to refuse a booked service if she feels the session(s) will not be a good fit for the client/practitioner relationship. If this happens the practitioner will refund your your service in full immediately.

​

14. I understand that packages purchased are only Valid for 1 year from the date of purchase.

​

15. I understand that an appointment/session will not be refundable if not cancelled with at least 24 hours notice.

​

16. I understand that this also applies to any pets, should I schedule sessions for them at any time in the future, and that these sessions are not a replacement for training or veterinary care.

​

PRIVACY POLICY:

Rene Bandy. with Mindful Balance with Rene' LLC, will not release your information without your written consent.  However, there are are exceptions where I may need to violate your privacy should the law require me to do so.  Some examples of when I may be required to report include, but are not limited to:Preventing a serious or imminent threat to self or the public, Child Abuse, and Sex Trafficking. 

​

Screenshot 2024-01-23 at 12.03.30 PM.png
bottom of page