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New Client Consent Form


Please fill out the following consent form before your session with Replenish Healing. All the information you provide will remain completely confidential. If you have any questions then please don't hesitate to contact me.

Client Details
Is a Parent/Guardian filling out this form?

Client's Rights 1. Unless there is an emergency, all sessions are private and confidential with the exception of specific exceptions described below: •Child, elder or dependant abuse, •Expressed threats of violence toward an ascertainable victim, •Detailed planning or concrete signs of future suicide attempts, •Sharing information is necessary to facilitate client care across multiple providers, •Sharing information is necessary to find the best solution for the client •Requests from legal and administrative institutions. 2. With the Client's prior written consent, the Replenish Healing may legally speak to another healthcare provider or Client's family members in emergency situations. The Client may direct the staff member of Replenish Healing to share information with whomever the Client desires, and the Client may change his/her mind anytime and revoke the permission. 3. The staff member is allowed to keep notes of any session which shall be kept in strict confidence. The Client may, at any time request a copy of the notes kept during any Homeopathy consultation / Reiki, Atua Healing session. 4. The Client may ask questions on what to expect during and end result of the Homeopathy consultation / Reiki, Atua Healing session 5. The Client may cease to continue Homeopathy, Reiki or Atua Healing anytime, without any impediment and may return to Replenish Healing at any time. 6. Amanda Cowlrick the owner of Replenish Healing has the right to dismiss the Client from the course of any Homeopathy consultations / Reiki, Atua Healing sessions, but only after a discussion with the client and if no resolution can be found. Acknowledgement I have reviewed this Professional Informed Consent Agreement. I accept this agreement and consent to working with the staff of Replenish Healing


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