New Client Intake Form

Liability Waiver

ENERGY SPACE ®

with Shelby Glidden

Services Offered / Theoretical Approach:

I offer my services as a complementary and alternative healthcare practitioner. I am not licensed, certified, or registered by any state as a healthcare professional, nor am I subject to licensure, certification, or registration.

Outcome Expectations / Risks & Benefits:

By engaging in my services, you understand that there are numerous benefits possible through ENERGY SPACE ® Such as increased relaxation, relief from anxiety, improved sleep, and diminished pain sensation. Please note that it’s impossible to guarantee any specific results and these effects may vary depending on each individual’s response patterns. Side effects may include, but not limited to: emotional release, lightheadedness, mild fatigue, physical tingling, and change in body temperature.

Purchase & Cancellation Policies:

Regardless of arrival time, sessions will end at scheduled time. To avoid being charged, notice of cancellation per service policy is required for session. Late cancellations and no-shows will be charged the full amount of the scheduled session. Advanced payment is required to schedule a session. Accepted forms of payment are credit cards.

Privacy Notice / Disclaimer:

I am providing you with the following information so you can make an informed choice about your decision to engage my services. Please read this information carefully and let me know if there is any part you do not understand. No information about any client will be discussed or shared with any third party without written consent of the client or parent / guardian if the client is under 18. I do not provide services for clients younger than 11 years of age. All clients between 11-18 years of age must have parent / guardian consent. All are welcome. We do not discriminate on the basis of race, color, religion / faith, creed, sexual orientation, gender identity, gender expression, national origin or ancestry, citizenship, military status, age, income, background or ability / disability. If for any reason we determine it is not a good fit between practitioner and client we will recommend another practitioner for you if possible.

Health & Safety:

My services are not a replacement for proper medical treatment and / or care. Please consult with a qualified and licensed physician or other medical care provider before attending a session. Please consult your physician if you suffer from the following ailments:

Epilepsy

Neurological Disorders

Heart Conditions

Pacemaker

Aneurysm

Meningitis

Severe unexplained internal pain

Hemorrhage, atherosclerosis / arteriosclerosis

Pregnant or trying to conceive

Hemophilia Organ Failure

Appendicitis

Metastatic Cancer

Lung abscess or tumor

Sepsis or bacteremia

Areas of acute inflammation

Beurger’s Disease

Agreement of Release & Waiver of Liability:

1. I will receive information and instruction while participating in class / session offered. I recognize that this will require physical exertion, may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in class / session or any other activity associated. I represent and warrant that I am physically fit and have no medical conditions that would prevent my full participation in class / session.

3. I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I may incur as a result of participating.

4. I knowingly, voluntarily and expressly waive any claim that I may have against ENERGY SPACE® (with Shelby Glidden) for injuries or damages that I may sustain as a result of my participation. As such I will not hold my practitioner liable for any adverse effects of such sessions on any health conditions.

5. My heirs, legal representatives and I forever release and waive any liabilities against ENERGY SPACE LLC (with Shelby Glidden) for any injury or death incurred by my voluntary participation in session.

The information provided by ENERGY SPACE LLC is for general informational & educational purposes only & does not serve as a substitute for medical advice. Accordingly, before taking any actions upon such information, we encourage you to consult your appropriate healthcare providers. We do not diagnose or treat medical conditions.