Client Disclosure Form

Heartfelt Wellness - Client Disclosure

Name:*
Date:*
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Welcome to Heartfelt Wellness I am a Classical Homeopath and Transformational Coach. I am NOT a licensed physician, therapist, or psychologist nor are my services licensed by the State of California. Homeopathy is one of the leading health care systems around the world, treating an estimated 500 million people. It offers holistic, non-toxic, low-cost health care through the application of individual remedies chosen from more than 2,500 FDA-approved remedies in the Homeopathic Pharmacopeia of the United States. Homeopathy provides therapeutic, curative and preventative effects based on the Law of Similars (“like cures like”) and a process of potentization that developed from the scientific work of German physician Samuel Hahnemann over 200 years ago. As a homeopath, I will provide you with the following services: Case taking: In-depth interview to record your physical, mental and emotional characteristics and symptoms. Case Analysis & Recommendation: Evaluation and cross-referencing of reported symptoms based on education, experience and computer technology. The goal is to identify one homeopathic remedy that best matches your symptom picture. Follow-up: Monitoring your case to evaluate how you improve or change during treatment. Adjustments to remedy and potency aim to achieve the most rapid, gentle and permanent restoration of health. As a Transformational Coach I will provide you with the services: I will facilitate the Faster EFT techniques and show you how to use this empowering self-healing tool in order to relieve stress and gain personal control over your emotions. We will work together to address the core issues of your problems such as, traumas, blocks, and limiting beliefs so that you can live a happier, healthier and fulfilling life. I, Elizabeth Valdez, have been studying homeopathy since 2002 and subsequently enrolled in a three-year program at the Homeopathic Academy of Southern California in Carlsbad, California and graduated in 2009. In addition, I have also been personally trained by Robert G. Smith, creator of Faster EFT, and I am currently a Faster EFT Level III Practitioner. I regularly attend seminars and conferences taught by today’s most renowned homeopaths in order to stay up-to-date. I hold the credentials of Classical Homeopath, CCH (Cand) and Certified Transformational Coach. I am also a member of the National Center for Homeopathy. To use my services, California state law requires that you acknowledge receipt of the information provided in this form by signing it. You will receive a copy. I will keep the original in my records for at least 3 years. If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. My method of treatment, classical homeopathy, 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 Profession’s Code. I can offer you these services, subject to requirements and restrictions that are described fully below. Please initial your acceptance of these sections of SB-577, California Business & Professions Code:

Section 2053.5: I, the client, understand that this treatment will NOT include any of the following by the provider: puncturing of my skin, invasion or insertion into my body, X-rays or prescription for X-rays, giving or prescribing of legend drugs or controlled substances, telling me to discontinue any legend drug or controlled substance prescribed for me by an appropriately licensed practitioner, diagnosing of physical or mental disease, setting of fractured bones, or the use of electrotherapy to treat lacerations [cuts] or abrasions [torn] skin.

Section 2053.5 Initials:
Section 2053.6(2): I, the client, have been given my own copies of this form and any other written materials, as may be indicated above; I have initialed each topic to indicate my understanding or receipt.
Section 2053.6(2) Initials:

Section 2053.6(b): I, the client, have been provided with this information in a language that I understand.

Language:
Section 2053.6(b) Initials:

Acknowledgment and Consent to Receive Services:

I have read and understand the above disclosure about the homeopathic treatment and transformational coaching sessions offered by Elizabeth, and have familiarized myself with her training and education. I have discussed with Elizabeth, the nature of the services to be provided. I understand that she is not a licensed physician and that homeopathic services or coaching sessions are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself with a medical doctor. I have consented to use the services offered by Elizabeth, and agree to be personally responsible for all fees accrued in connection with the services provided to me.

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