Client Release Form

MAIL TO: Energy Healing Partners, Inc., 11062 Desert Sky Loop, Redmond, OR 97756.         

I, (name) ____________________________request that Mary “Mo” Wheeler provide a Creative Energy Healing session for

myself
(name of recipient) __________________________

for the purpose of promoting and supporting the named person’s own healing ability.

I have read the description of Creative Energy Healing on this web site.
I have no question about the material in that description.
I will discuss with Mo Wheeler all questions which I have.

DISCLAIMER

I understand that Mo Wheeler is a healer and is not working with me in the role of a psychologist, psychotherapist, or medical doctor. She has developed her own techniques. This has been her own learning from her Higher Power and her own experience rather than from any formal education. There is no research available at this time to support her healing work.

I understand that Mo Wheeler does not perform “miracle cures.” Creative Energy Healing is not intended as diagnosis, prescription, treatment or cure for any disease, disorder, or injury, mental or physical. Any healing that may or may not take place subsequent to healing sessions is up to Divine intervention.

I understand that Mo is not licensed to diagnose or treat illness or disease in the same manner as a medical doctor, and that Creative Energy Healing is non-medical in nature and is not being recommended or performed as a rendering of medical services. Healing sessions are intended to support and promote whatever medical advice I am receiving. Sessions are not intended as a substitute for regular medical care. Medical treatment should be an important part of your overall health plan.

I understand that Mo is not licensed to prescribe pharmaceutical or herbal remedies. Should I decide to use any ideas, exercises, or other suggestions, I do so at my own risk.

I understand that I retain responsibility for all of my present physical and mental symptoms as may be appropriate. I understand I am not being discouraged from seeking treatment from a physician, other psychotherapist or similar profession. All aspects of the problem need to be considered and treated by the appropriate resource.

I understand that Mo Wheeler will only provide healing sessions if the recipient agrees to maintain his or her relationship(s) with medical physicians, health-care practitioners, and/or other therapists, and I agree to do that. I understand that it is usually helpful to coordinate treatment with your physician or other health care provider and I will take responsibility for initiating this coordination.

I understand that a follow-up session may be needed in 10-24 weeks, and I agree to arrange for this session.

I understand that scheduling an appointment is contingent on being accepted by Mo as a recipient of a healing session, and that her not accepting me is in no way a negative reflection on me. This may not be the best time for a healing session with Mo, or I may be better helped by other resources.

I have read the Disclaimer above and understand its contents.
I would like to discuss the possibility of a scholarship.

Signed _____________________________________

Date _________________________

Email address (Please print clearly.) _____________________________

Phone _____________________________ Day _____ Evening _____

Best times to call ____________________________________________

Time Zone _____________________________________________________

Preferred time for session:
[Please indicate preferred times Monday through Friday between 8:00 a.m. and 5:00 p.m., USA Pacific Time.]

______________________________________________________

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MAIL TO: Energy Healing Partners, Inc., 11062 Desert Sky Loop, Redmond, OR 97756