Ruth Kellogg Client Intake & Waiver Form
ATTENTION: PLEASE DO NOT FILL OUT WAIVER until you have contacted me for session availability ( Sometimes, my schedule gets booked and I don’t have space for new clients. If I am not available, I’d be happy to send you a referral list.

This form is an important legal document. It explains the assumption of any and all risks in deciding to follow the advice or insight of Ruth Kellogg, who operates as an advising consultant. It is critical that you read and understand it completely. After you have done so, please print your name and sign in the spaces provided at the bottom.
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Ruth Kellogg is in private practice for the purpose of providing support using an eclectic combination of Energy Healing, Spiritual and Intuitive Guidance, Coaching, Consulting via mind/body/spirit healing “Techniques.” Each session is a potential and revealing experience that unfolds. Listening to the energetic messages of the body, intuition, and Spirit, Ruth uses various mind/body/spirit “Techniques” including but not limited to conversation, guided meditation, visualization, spiritual and intuitive guidance, and energy healing.

The idea behind the mind/body/spirit healing “Techniques” is to support the client to connect to his or her body’s innate wisdom and intuition. These healing services and “Techniques” have both benefits and risks. Potential benefits include releasing emotional and physical pain and limiting beliefs, finding it easier to break free of stagnating patterns, and embracing a more awakened, healthier, joyous life—one that is in alignment with the client’s potential. Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration) or the recall of unpleasant events in one’s life. It may be likely, but not always the case, to experience tiredness or an increase in energy in the first few days following a session. The services provided (including but not limited to energy healing, spiritual and intuitive guidance, coaching, consulting) are currently not licensed by the state of California, thus Ruth Kellogg is not licensed by the State of Ca as a healing arts practitioner. She is licensed in the state of California as a Psychotherapist (LCSW). Coaching and Energetic Healing are not psychotherapy. While a portion of what we do will fall into that category, not all of what we do does.

Ruth Kellogg has practiced energy healing, spiritual and intuitive guidance and coaching since 2008. She is a non-denominational ordained Shamanic minister and practitioner through Venus Rising. She has a Master’s degree in Social Work and is a Licensed Psychotherapist/LCSW #10387 in California since 1983. She holds certifications and/or received training in Gestalt Therapy, Emotional Release, Matrix Energetics, Theta Healing, and Advanced Space Healing. Please feel free to discuss any questions you have regarding Ruth Kellogg's training and background or the services provided.

Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum 48 hours (2 full days) notice is required for re-scheduling or canceling an appointment. A fee of $100 will be charged for sessions missed without such notification.
Services are provided at the rate advertised or discussed for the time spent together. Payment is due before sessions begin or via the payment plan discussed. Ruth Kellogg reserves the right to increase rates at any time.

Please note that there are certain limitations for sessions or communications conducted using telecommunications (e.g., phone, Skype, Facetime, Zoom, etc.). The Internet, mobile or wireless phones, and email may not always be entirely private; therefore, Ruth Kellogg cannot control, or be held liable for the outcome. However, she will do her best to maintain privacy and respect HIPPA laws. Your information will never be shared without your written consent.  
I acknowledge that I have read and understood sections entitled, The Process, Training, and Licensure, Cancellation, Fees, and Privacy described above. I recognize that this is not in total psychotherapy and Ruth Kellogg is not a licensed physician and in no way does Ruth Kellogg provide legal, medical, or psychotherapeutic medical advice. It is my responsibility to secure such advisement. I acknowledge and agree that I assume the risks associated with any and all activities, classes and/or programs in which I (or my child) participate. Any claims, declarations and statements made on the website, also holds no guarantees.

I hereby acknowledge I (or my child) has volunteered to participate in a paid or unpaid session(s), class(es), workshop(s), or program(s) with Ruth Kellogg, to include, but also may not be limited to, any and all services provided, such as energy healing, spiritual and intuitive guidance, coaching, consulting, classes, programs, products, and workshop attendance. I further acknowledge that no promises have been made regarding results or desired outcome. In consideration of Ruth Kellogg’s agreement to instruct, guide, assist, advise, or train me, I do here and forever release and discharge and hereby hold harmless Ruth Kellogg, and her respective agents, from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my (or my child’s) participation in a session(s) or purchase of any program(s) without limitation, which may occur as a result of following advice provided or training rendered during a session or event.

I have consented to use the services offered by Ruth Kellogg, and agree to be personally responsible for the fees of Ruth Kellogg in connection with the services provided to me.

In order to use my services, please acknowledge receipt of the information provided in this form and sign it below. You can also respond by email by copying and pasting the paragraph below. Your receipt of information by email or below will act as your acknowledgment and signed agreement. You will receive a copy. Ruth Kellogg will keep the original in her records for at least three years.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Ruth Kellogg from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

I acknowledge that I have read this waiver and release. I fully understand that it is a release of liability. By forwarding this by email or signing below I am waiving any rights I or my successors might have to bring legal action against Ruth Kellogg.
ELECTRONIC SIGNATURE AGREEMENT: By selecting the "I Accept" button below, you are signing this Agreement electronically and are legally bound to its terms & conditions. You agree your electronic signature is the legal equivalent of your manual written signature.

E-SIGNATURE: I have read and agree to the Waiver, Release, and Assumption of Risk *
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