Avesah Client Consent Form

Client Consent Form

Establishing a safe and clearly communicated container in which we can work together is extremely important. The following outlines some important acknowledgements and agreements required to ensure the work you do is as beneficial, safe and productive as possible.

If you have any questions or concerns to be addressed before completing this form, please contact me immediately.

"*" indicates required fields

Name*

First Last

Email*

Phone*

Response Awareness*

I am aware that participation various modalities of movement, yoga, breath work, body work, energy work, mindfulness and other practices and exercises that I may learn or undertake with Avesah can arouse emotional pains, wounds, distress, and/or other responses. By participating and attending sessions, I assume the risks connected with the voluntary participation in these activities.

I agree (check here)

Health Acknowledgement*

I represent that I am in good physical and emotional health, and/or have obtained written approval from a health care provider. This means that I have no physical or emotional impairment which would limit my participation in these activities, or place me at an elevated risk of having a significant physical, emotional or mental reaction to the work I am doing. I recognize that it is always advisable to consult a physician before beginning any type of physical activity program, and I have been encouraged by Avesah to do so.

I agree (check here)

Ongoing Communication*

I understand the importance of keeping my facilitators/coaches/instructors informed of any health concerns that may develop. I agree to take responsibility for my safety and well-being by listening to my body and intuition, and to communicate any concerns or needs to accommodate or adapt the work I am doing with my facilitator.

I agree (check here)

Medical/Therapy Treatment*

I acknowledge that I will continue any medical treatments that I am currently engaged with, such as medication, psychotherapy, counselling, etc. I acknowledge that the services Avesah provide are not intended to replace or substitute for traditional medical and mental health professionals, and that I have been strongly encouraged to maintain regular counselling sessions with a licensed psychologist or therapist along with the work I do with Avesah. I understand that Avesah and its facilitators are not licensed medical doctors and are not intended to replace licensed medical professionals.

I agree (check here)

Medical/Diagnosis Waiver*

I understand that Avesah has not and will not render any medical services including a medical diagnosis of my physical or mental condition, or prescribe any treatments or supplements. I specifically agree that Avesah, its employees, directors, contractors, agents and/or yoga facilitators shall not be liable for any claim, demand, cause of action of any kind resulting from or related to the my participation in any programs, sessions, coaching or sessions of any kind offered by Avesah. Further, I agree to hold Avesah, Missy Habstritt and staff harmless from the same.

I agree (check here)

Client Consent Form

move. breathe. heal.