Forms — Heart Rooted

Client Disclosure and Consent Form

Welcome to Heart Rooted Health!

I am a practitioner of Bio-Energetic Synchronization Technique (B.E.S.T.). B.E.S.T. is a non-forceful, energy balancing procedure used to reestablish the full healing potential of the body using its natural healing abilities. The theory behind B.E.S.T. is that it removes interference and/or distractions that are demanding the attention of the healing power, thereby causing imbalance in the autonomic nervous system, and ultimately leading to dis-ease. B.E.S.T. is state of the art in balancing body, mind, memory and spirit energy fields, and enhancing the flow of that energy throughout the entire system. It is a whole-body healing technique.

As a practitioner of B.E.S.T., I will provide you with the following services:

- By accessing areas of the brain in a specific sequence, the body begins to reconnect the circuitry with the brain.

- Integrative breathwork and mental focus training is used to remove blockages from the nervous system and subconscious memory storage.

- Wellness and/or lifestyle coaching may be included.

My training and education is described below:

Certification as a B.E.S.T. practitioner through Morter Health Alliance, having completed intensive study in the B.E.S.T. Technique and having passed practical and written examinations.

I am not a licensed physician, nor are B.E.S.T. services licensed by the State of California.

My method of treatment is alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you these services.

In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. I will keep the original in my records for at least three (3) years.

If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor that you are receiving B.E.S.T. treatment.

Acknowledgement and Consent to Receive Services:

I have read and understand the above disclosure about the B.E.S.T. treatment offered by Natasha Davidson. I understand that Natasha Davidson is not a licensed physician and that B.E.S.T. services are not licensed by the State of California. I understand it is my responsibility to maintain a relationship for myself, if I so choose, with a medical doctor. I have consented to use the services offered by Natasha Davidson, and agree to be personally responsible for the fees in connection with the services provided.

I have read and understand the above.

Type Signature Here:

Name

First Name

Last Name

Date

MM

DD

YYYY

Email