Consent Form

I, the undersigned, understand that:  

1. Nisa King ("this Support Provider") is not a medical doctor, naturopathic physician, psychologist, licensed clinical social worker or psychiatrist. This Support Provider does not claim to, nor does she represent to be, a licensed health care provider of any sort.  

2. This work is not offered as a replacement or substitute for mental health care treatment with a licensed mental health care provider, but rather as an optional, supportive and educational service.  

3. This Support Provider does not take any legal or clinical responsibility for the health or welfare or mental health care of the undersigned ("the Client"). The licensed health care providers which the Client has engaged are the only entities who are legally and clinically accountable for the health and welfare of the Client, even if the Client is referred to this Support Provider by a licensed health or mental health care provider.  

4. This Support Provider does not offer diagnosis, treatment or cure for any physical, mental or emotional health care problem, disorder or illness.  

5. This Support Provider offers the Client an environment that may promote conscious health and well-being which may improve the Client’s ability to accept and meet life's challenges.  

6. All information given to this Support Provider is confidential. Information will only be disclosed with the written consent of the Client. However, if the Client discloses the potential of the Client harming him/herself and/or others, or if the information is revealed indicating the potential or actual harm of a child, this Support Provider will disclose this information to the appropriate authorities.  

7. No third party, including assistants or members of the Client's family, if the Client is over the age of 19 years, maybe present during the course of a session with the Client without the express consent of the Client and this Support Provider.  

I have read and I understand all the statements above, and I agree to these terms. I certify that I am under, or will seek, the care of a licensed health care provider, if I believe I have, or am aware that I have serious mental, physical or emotional problems or illness. I agree that I will not terminate conventional and/or alternative treatment with a licensed and qualified healthcare provider(s) as a result of this work.  

I, the undersigned, do not hold Nisa King legally or clinically responsible for any aspect of my physical, mental or emotional health or care thereof.  

I herewith request Nisa King to provide education, support and resources to me regarding conscious health and well-being.