Disclosure and Consent
Please read through information, check each section to confirm you read and understood each section. Then type name to electronically sign the form.
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Disclosure
Disclosure
I, Keslie Mack, am an Intuitive Mind-Body Pain Release Specialist, Certified Reiki Master Instructor, Certified Hypnotherapist, Essential Oils Educator, and a Medical Intuitive. I have been in practice for 2 years. I have received formal training for the certifiable modalities above. No type of work I do is licensed by the state of California. 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. You will receive a copy upon request. I will keep the original in my records for at least three years.

My method of treatments and classes are 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, subject to requirements and restrictions that are described fully on this page.


Nature of the Services and Classes Provided:
My sessions are tailored to each client and may combine any or all of the above modalities, based on client request or practitioner evaluation.

In-person sessions:
All in-person services offer the client the option of laying or sitting and the option of hands-on healing or hands off healing (hand will be kept 4 to 6 inches away from the body at all times) if the session requires such healing. In either case, the client will remain fully clothed during the session.

Online sessions:
Sessions completed via Video Conference Online will be conducted as such and the client will be fully clothed and sitting or laying in their location as they see fit.

Self-healing classes:
Self-healing classes are held in-person or online and are limited to 9 participants due to insurance limitations. Classes combine training and information of the above modalities in addition to trigger point theory, acupressure, reflexology and yoga.


Theory of Treatment
Intuitive Mind-Body Pain Release:
Using a combination of modalities listed below, pain is allowed to be released naturally and easily.

Reiki:
Reiki is a form of energy healing that is over 150 years old and is practiced in many countries throughout the world. It brings balance to the natural flow of "ki" (life force energy through the body).

Hypnotherapy:
Hypnotherapy is a natural and effective technique for accessing the subconscious mind. It creates a window into the body, via the mind, allowing you to access the information you have stored deep inside, bring it to the surface and make a decision based on the findings of what action you would like to take next.

Mind-Body Connection:
Mind-body work is the theory that our minds and bodies are constantly in communication and anything that affects one will, in fact, affect the other. Thoughts, feeling, and beliefs all have an effect on our physical bodies and by treating both, healing is able to happen more easily.

Chakra Balancing:
Chakras are energy centers in the body and have been used and studies for thousands of years to aid in healing and to obtain optimal health. When these centers are out of balance, you will see disruptions to the homeostasis of an individuals mind, body and spirit.

Medically Intuitive Readings:
I have the ability to see/sense into painful symptoms to help clients determine the underlying cause and what is needed to heal it. Painful symptoms may be caused by energetic imbalances, thoughts or beliefs, trauma, or other past experiences.

Essential Oil Therapy/Aromatherapy:
Essential oils and their benefits are widely researched and backed by science. Essential Oil Therapy/Aromatherapy is a holistic healing treatment that uses natural plant extracts to promote health and well-being. Aromatic and topically applied essential oils are used medicinally to improve the health of the body, mind, and spirit. It enhances both physical and emotional health.

Acknowledgment and Consent to Receive Services:
I have read and understood the above disclosure about the sessions and classes offered by Keslie Mack and Keslie Mack’s training and education. I have discussed with you, the client/student or parent/guardian of the client/student, the nature of the services and classes to be provided. I understand that Keslie Mack is not a licensed physician and that none of the services or classes she provides are licensed in the State of California. I understand it is my responsibility to maintain a relationship for myself or my child/ward with a medical doctor if necessary, as Keslie’s services are not substitutes for medical advice or physician-prescribed treatment.

Payment Policies
All payments for sessions and classes are due prior to start of session or class.

Sessions:
A 24-hour notice is required if you are going to cancel or reschedule a session. Failure to do so will result in the session being forfeited and you will not be refunded, nor will you be able to reschedule.

Classes:
If you can not attend a class in a series, you will receive any recordings, assignments and the information that was taught. There is no option to make up a class at this time.

Typing my name below verifies that I have read and understood the above disclosure and payment information and I agree to to receive a session or attend a class taught by Keslie Mack. *
A copy of your responses will be emailed to the address you provided.
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