Client Intake & Liability Waiver Form

1) Please READ below and FILL out all the information below to get started.

2) TEXT 587-645-0880 to make an appointment with Anna

TEXT 780-804-0517 to make an appointment with Andrew

You will also receive your appointment reminder 24 hr before your appointment.

Please note that there is a cancellation and no refund policy in effect listed below.

By filling out this form you are accepting this waiver & release of liability & all of the terms and conditions indicated below.
Thank you.
Email address *
First Name *
Your answer
Last Name *
Your answer
Mobile Number *
Your answer
Street Address *
Your answer
City, Province, Postal Code *
Your answer
Gender *
Your answer
Birthday *
Emergency Contact, Phone Number, Email & Relationship to you
Your answer
How did you hear about us? OR from whom? *
Your answer
What are your major concerns *
Your answer
What are your goals & expectations? *
Your answer
Please list mental, medical diagnosis/conditions and allergies. *
Your answer
List any surgeries or injuries *
Your answer
List any medications you are on & what they are for *
Your answer
Where do you work and what do you do? *
Your answer
If you are going to school where and what are you taking? *
Your answer
Have you seen a personal trainer before? *
Have you seen a counsellor? *
Have you seen a holistic practitioner if yes what kind of modalities? *
Your answer
Have you suffered from suicide ideation? *
If yes to the above, do you still currently have suidical ideation? Are you receiving mental health support for it? *
Your answer
Have you been charged for any type of assault or domestic abuse charges? *
Have you been mandated by the courts to seek counselling? *
If you answered yes to: “suicide ideation and/or being charged for assault or domestic abuse, and/or mandated by courts” you will immediately be referred to other mental health services or other professionals that can assist you further. In the event any of the criteria above occurs during therapy you will be referred you will also be immediately referred to mental health services or other professionals that can assist you further. Do you agree to these terms? *
Although, we cannot guarantee your preferred time slots will align with our availability, and we may be waitlisted from time time, we can ensure to place you on our waitlist/cancellation list. Please list your General Availability during the week. (We our Closed Sundays) *
Your answer
What are services are you interested most in? *

I understand that Anna Trillana of Infinite Strength is a Registered Professional Counsellor, Certified Clinical Hypnotherapist; A Certified Master/Instructor in: Usui Reiki; Kundalini Reiki, Celtic Reiki, Huna Reiki, Hot Stone Reiki, Lightarian Enlightment Rays Reiki, Karuna Ki Reiki, Shamballa Reiki, Seichim Reiki; Integrated Energy Therapy® Angel Therapy, a Registered Certified Yoga Teacher, Certified Sound Coach, Licensed Spiritual Coach, Spiritual Response Practitioner SRT/SpR, Qi Gong teacher/practitioner and Certified MDS (TM) practitioner. She may incorporate any of these modalities during individual or couple session via in person, phone or online sessions.

I understand that the above modalities can assist me in:

• Learning how to relax to reduce stressors
• Refocus my thoughts to regulate my emotions
• Breathing Techniques, Meditation, Manage my pain
• Improve my mental functioning & enhance my quality of my life through recognizing my inner tools and resources to be more empowered to make more informed decisions with my health and wellbeing in a more positive direction
• Provide yoga or Qi Gong poses and techniques to release physical tension and tightness and progress in improving my range of motion
• During Certified Courses she will coach me, train me, empower me, explain, instruct, mentor, quiz for knowledge, supervise, teach and test for knowledge


I understand this is a professional therapeutic relationship and it is uniquely and highly personal, at the same time is a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together.

I understand that Anna Trillana of Infinite Strength cannot promise that my behaviour or circumstance will change, however I understand she will do her very best to understand me and any repeating patterns, as well provide clarity through paraphrasing and summarizing my dialogue.

I understand that my treatment plan depends largely on my willingness to engage in this process, which may at times, results in considerable discomfort.

I also understand that I must disclose any mental health or medical diagnosis or discomforts that I’ve experienced in the past or presently to ensure my therapeutic needs are being customized appropriately for me.

I understand that therapy exposes me to experience emotional issues while I am healing myself in any of my sessions with Anna Trillana of Infinite Strength, and remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures, nor can I blame my discomforts as I have I understood that it is part of therapy.

I understand that Anna Trillana of Infinite Strength is not be used as a scapegoat during/outside of session time, therefore I understand that I will not blame in person or other forms of communication such as email/text her inappropriately for an discomforts experienced during/outside session time.

I understand that individual therapy involves Anna Trillana and myself working together as a team; to help me to learn to regulate my emotions and effectively communicate with others and self realize. Thus, seeking Anna Trillana's opinion/validation is contradictory to therapy.


I understand that should I want to switch from an individual therapeutic relationship to a couples therapeutic relationship or vice versa the format of counselling shall change. I understand that couples therapy will sometimes involve 1-on-1 sessions with each partner to incorporate a broader view of the relationship concerns, however, any individual/couples work may have to be referred to another counsellor depending on the agreement between myself and Anna Trillana of Infinite Strength, to avoid conflict of interest in the couples therapeutic relationship.

I understand that Anna Trillana of Infinite Strength is not be used as a scapegoat during/outside of session time, therefore I understand that I will not blame in person or other forms of communication such as email/text her inappropriately for an discomforts experienced during/outside session time.

I understand that I will not seek to take my partner to couples therapy to receive validation from Anna Trillana of Infinite Strength if my beliefs are right or wrong. I understand that couples therapy involves Anna assisting my partner and I to learn to communicate more effectively. Thus, seeking Anna's opinion/validation is contradictory to therapy. Lastly, I also understand that Anna will refer me to another therapists for any parenting issues that may arise.


Group Classes & Workshops can be a powerful and valuable venue for healing and growth. It is the desire of Anna/Andrew that you reap all the benefits group has to offer. To help this occur, groups are structured to include the following elements:
- A safe environment in which you are able to feel respected and valued as you work
- An understanding of group goals and group norms
- Investment by both Anna/Andrew and members to produce a consistent group

A safe environment is created and maintained by both Anna/Andrew and its members. Primary ingredients are mutual respect and a chance to create trust. Another primary ingredient for a safe environment has to do with confidentiality. We realize that you may want to share what you are learning about yourself in group with a significant other. This is fine as long as you remember not to talk about how events unfold in group or in any other way compromise the confidentiality of other group members. Classes maybe recorded by the permission and request of the members and are to only be shared within the group members, this is not always available, however, Anna/Andrew will discuss previous to the class starting if a recording will be made available to the group members.


I understand I will make use of the resources below if I need to discuss concerns outside my appointed session. If at any time I feel like harming myself or injuring another, I will let the group leaders know and or contact my individual therapist or psychiatrist. If I cannot reach them, I will call either 911 or the SOS Crisis Line at 780-743-4357 (24hr Crisis Line) or go to Queen Street Facility or Northern Lights Hospital in Fort Mcmurray or the nearest emergency care center.

I also understand and accept that the therapeutic relationship with Anna Trillana of Infinite Strength will be terminated immediately should I require further mental health or other professional authorities’ assistance if there is disclosure of suicide ideation or domestic violence. A safety plan, referrals to professionals and services will be provided to me and if necessary authority measures will be acted upon to ensure my safety.


I understand that if I need to contact Anna Trillana between sessions, I can email her and I understand that she will reply within 36 hr during business days.

There will be NO TEXTING for any issues, concerns or questions. TEXTING IS ONLY FOR APPOINTMENT SCHEDULING.

I understand that Anna is not often immediately available; however, I understand Anna Trillana will make the attempt to return my call/email within 36 hours. Hence I will make use of the after hours/after session resources (SOS Crisis Line, 911, local emergency facilities).

Any messages sent after Friday 9 pm – Sunday 6 pm. I understand they will not be reviewed till Monday. I understand that it is best to discuss concerns at my appointed session.


I understand that Anna Trillana cannot ensure the confidentiality of any form of communication through electronic media, including text messages. Communication via email or text messaging are only permitted for issues regarding scheduling or cancellations; while Anna Trillana may try to return messages in a timely manner within 36hrs during business times, Anna Trillana cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.


I understand that if I am a minor, my parents may be legally entitled to some information about my therapy. Anna Trillana will discuss this with me, and my parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.


Telepsychology refers to counselling services that remotely use telecommunications technologies, such as video conferencing or telephone. One of the benefits of telepsychology is that the client and the therapist can engage in services without being in the same physical location. Although there are benefits of Telepsychology, there are some differences between face-to-face counselling and Telepsychology, as well as some risks. For example:

Because the Telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. As your therapist, Anna will take reasonable steps to ensure your privacy but it is important for you to make sure you find a private place for the session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in Telepsychology only while in a room or area where other people are not present and cannot overhear the conversation.

There are many ways that technology issues might impact Telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. Your therapist has a legal and ethical responsibility to protect all communications that are a part of Telepsychology, for example ensuring that the platform used is PHIPA compliant.

As your therapist, Anna has the right, at any time, to determine if Telepsychology is not appropriate for your situation. Should this be determined, I will provide you with referral information to other, more suitable, services.
Confidentiality: The extent of confidentiality and the exceptions to confidentiality outlined in Tacit Knowledge’s Informed Consent document apply in Telepsychology;

The Telepsychology sessions shall not be recorded in any way. As your therapist, Anna will maintain a record of the session in the same way had the session been conducting face-to-face, in accordance with the policies/ethical standards outlined by both of my registering bodies - the CPCA and ACTA.

When engaging in a Telepsychology session, please also keep the following in mind: -ensure you are in an appropriate location (free of distractions like family and pets if possible); -verify ahead of time the best reception in your chosen location; -dress appropriately as you would for a session; -refrain from eating and/or smoking during the session as these can create communication challenges.


Ending relationships can be difficult. Therefore, it is important to have am appropriate termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment decided by both Anna and myself.

Anna Trillana may terminate treatment after appropriate discussion of the termination process. If Anna Trillana determines that the therapy is not being effectively used or if you are in default on payment, Anna Trillana will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating.

If therapy is terminated for any reason or you request another therapist, Anna Trillana will provide you with a list of qualified therapists to treat you. I understand I may also choose someone on my own or from another referral source.

I also understand and accept that the therapeutic relationship will be terminated immediately should I require further mental health or other professional authorities’ assistance if there is disclosure of suicide ideation or domestic violence. A safety plan, referrals to professionals and services will be provided to me and if necessary authority measures will be acted upon to ensure my safety.

Should I fail to schedule an appointment or communicate with Anna Trillana for two consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, Anna Trillana must consider the professional relationship discontinued.


I agree that I am here on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation. By signing below, I further agree that I will not hold Anna Trillana or Andrew Bambury of Infinite Strength responsible should there be any unfavorable outcome or result. I have read the above noted consent and have had the opportunity to question the contents and my therapy. By agreeing to this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed and any additional treatment as proposed by my therapist to deal with my physical condition(s) for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.


I have volunteered to participate in a fitness program provided to me by Infinite Strength, which may include, but may not be limited to, resistance training and aerobic or cardiovascular exercise. In consideration of Infinite Strength’s agreement to instruct and train me, I do here now and forever release and discharge and hereby hold harmless Infinite Strength and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise program including any injuries resulting there from.


I have been informed of, understand and am aware that any exercise program, whether or not requiring the use of exercise equipment, is a potentially hazardous activity.

I also have been informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved.

I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death.I have been advised that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise program, or initiating a substantial change in the amount of regular physical activity performed.

If have chosen not to obtain a physician’s consent prior to beginning this fitness program with Infinite Strength, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and/or exercises in which I participate.


This form is an important legal document that explains the risks you are assuming by beginning an exercise program. It is critical that you have read and understand this document completely. If you do not understand any part of this document, it is your ultimate responsibility to ask for clarification prior to accepting and clicking below.


Prices are subject to change.
I agree to present payment directly before/after services rendered.
I understand that should I choose to purchase a package they have an expiry from the date of purchase based on the package purchased.

I understand that:

1-ON-1 sessions are not applicable towards 2-ON-1 sessions. If one client doesn't show up for the 2-ON-1 booked session it is still considered a 2-ON-1 session.


5 sessions: 2 month
10 sessions: 3 month
20 sessions 5 months


I understand that the time of sessions involve:

Sessions are 50-60 minutes in length

I understand that I must be on time for my appointment and there will be no extra time provided at the time the session is scheduled to be over.

If I am late for a session, I understand I may lose some time during that session time


if it is a disruption to the session it can conclude in a loss of session (ie. 20-30 min left in a session is not sufficient for counselling & discussing matters that require more processing time)


I understand that there are no refunds policy in effect. I also understand and accept that expired sessions will not be refunded or honoured.

Clients are responsible to keep track of their sessions remaining.

Please contact to get receipts, payments settled, and session balance.


I understand and agree that I must provide at least 24 hours notice of cancellation or re-scheduled session or I forfeit the value of that session.i.e. I will be charged/loose a session from my package purchased.

A charge of $80 plus tax will be charged if there is no package purchased.I authorize my credit card information to be charged for the $80 plus tax Cancellation Fee based on these conditions.

I understand that this is necessary because of the time commitment made for me and it is held exclusively for me.


Infinite Strength collects, uses and discloses health information according to the Personal Health Information Privacy Act Infinite Strength is committed to take steps to protect your personal health information from theft, loss and unauthorized access, copying, modifications, use, disclosure and disposal and to protecting your privacy and only using your personal health information for the purposes you consent. Infinite Strength cannot reveal information about me without my written permission except where disclosure is required by law: “If I present imminent threat to myself or others; When there is an indication of abuse of a child, elder or dependent adult, If I become gravely disabled; By court subpoena.


I understand that I am responsible for my own health, healing and wellbeing. I also understand I have the ability to heal myself by reconnecting to the Source of all healing I understand it is my responsibility to advise Anna Trillana or Andrew Bambury of anything that might help us work together better to achieve the healing I seek. I further understand any services performed by Anna Trillana are not a substitute for adequate medical care and I intend to remain under the care of my primary healthcare provider.

I understand that if I have -- or if I think I have -- a medical/psychological or emotional concern, condition, disease, disorder, issue or symptoms, Anna Trillana or Andrew Bambury will help me reduce any related stress and consult with or refer me to other professionals in their areas of expertise in order to provide the best treatment for me.

I understand that Anna Trillana or Andrew Bambury will seek required law & medical attention/other professionals when my health and safety is in jeopardy; or I present imminent threat to myself or others; or if there is in indication of abuse of a child, elder or dependent adult; or if I become gravely disabled.

I agree that I am here on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation.

I understand if we see each other accidentally outside of the therapy office, Anna Trillana or Andrew Bambury may not acknowledge me first. It is my right to privacy and confidentiality and is of the utmost importance to Anna Trillana and Andrew Bambury, as they do not wish to jeopardize your privacy.

However, if I acknowledge Anna Trillana or Andrew Bambury first, she will be more than happy to speak briefly with me, however, Anna Trillana and Andrew Bambury feels it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

I have read all the terms & conditions above. I have filled out the information requested as 100% accurate and to the best of my knowledge. I accept this waiver & release of liability including all the terms and conditions indicated on this form. *
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