Please fill out the below forms and return it to our email and send a picture of the subject receiving the treatment to our Whatsapp 646-377-0448.

Bionetic Stress Assessment and Self-Regulation Counseling Authorization and Release Form

The Bio-Responses and Stress Point measurements taken during the Assessment session used by the Therapist, measure the electrical responses and energy flows of the body, aiding to identify various stressors that might impede the energetic and regulatory processes. The evaluation may include recommendations for natural remedies, exercise, stress reduction, detoxification, and/or nutritional changes designed to balance the energy meridians and enhance overall metabolism. The assessment process and related recommendations are not cures for any known diseases, nor have they been proven clinically to eliminate, prevent, or mitigate any specific disease process.The Bionetic Stress Assessment is not a method of diagnosing, or treating diseases, nor are the suggested remedies designed to replace any of the medications or treatments that the Client is currently advised to take by a primary care practitioner.

 

1. I fully understand that the attending consultant is not an allopathic doctor (M.D.) and does not pretend to be, but is a holistic Bionetic practitioner providing services that are not allopathic, but that are within the parameters of a natural health, physiology enhancement, energetic health, and wellness philosophies.

 

2. I fully understand that the attending consultant does not offer allopathic drugs, surgery, chemical stimulants or radiation therapy, or mitigation of disease processes, but is providing information and natural products to restore natural balance and optimum conditions for optimal physiological performance.

 

3. I fully understand that the consultant is not diagnosing or treating any illness or disease, but is assessing only the Bio-Energetic balances and overall stress-point responses of the body, and that these services may not be generally accepted and/or recommended by allopathic physicians or other licensed health professionals.

 

4. I fully understand that the attending consultant IS NOT encouraging me to terminate or modify any previous or ongoing medications under the direction of any licensed practitioner, and that the attending consultant can/will not dissuade me from seeking allopathic treatment from a licensed practitioner.

 

5. I presently seek consultation, advice, opinions and/or programs, tests, assessments and/or products within the scope of the attending consultant's practice based upon the principles of holistic Bio-Energetic health and have solicited the attending consultant's services in good faith, exerting my free will and following the dictates of my own conscience which allows me to select what I understand is most beneficial in optimizing my body’s metabolic function and enhancing my wellbeing.

 

6. I take full legal and total responsibility for any minor or incompetent accompanying me.

 

7. I authorize the attending consultant to provide their services to me on my behalf, and hereby release them from any and all claims and potential claims arising from my actions or failure to act upon their advice.

 

8. I give full faith that I have read and understand this document entirely, that I have received a verbal explanation of the same from the attending consultant and/or that he/she has answered satisfactorily all of my questions regarding the information on this document.

 

9. I am willing to declare under oath all of the above statements by request of the attending consultant.

 

I hereby consent to and authorize the above described evaluation and consultation:

 

Thanks for submitting!

Agreement for Services: Distance

The Distance services offered by “IN HARMONY HOLISTIC” are for biofeedback and bio-resonance therapy. It is sometimes referred to as Vibrational Medicine or Energy Medicine. However, the services offered by “IN HARMONY HOLISTIC” are not connected with traditional medicine as practiced by most western medical doctors and hospitals. Traditional medicine is based on biochemistry. Energy Medicine is concerned with biophysics. It is an entirely separate discipline concerned with the correction of energy fields, and with balancing the bio-electric frequencies of the human system.
I agree to undergo Distance Sessions at my own risk. I further indemnify and hold harmless “IN HARMONY HOLISTIC”, “JOSE HURTADO PRUDHOMME” and/or his affiliates, officers, as well as, any successors, assigns and executors, administrators, personal representatives, employees and heirs from any and all results of Distance Therapy or any other modality I receive from “IN HARMONY HOLISTIC” including The L.I.F.E. System (biofeedback therapy) and/or other energy instruments. 


This agreement shall be unlimited as to amount of duration, and it shall be binding upon and inure to the benefit of the parties, their successors, assigns and personal agents and representatives. “IN HARMONY HOLISTIC” technology or personnel do not diagnose, treat, prescribe, or claim to cure any disease.
Clients are advised that they should consult their own medical practitioners and medical professional for the diagnoses, care, treatment, or cure of any health condition. However, it is the intent of the “IN HARMONY HOLISTIC” to promote self-healing through information, biofeedback, frequencies, and emotional support. 


I understand that there are many kinds of energy frequencies that can include emotional, spiritual, and/or physical balancing.


I understand that positive results are not bound by time periods.


I am of legal age or have the agreement of my parent or legal guardian to seek the services of “IN HARMONY HOLISTIC” I am of sound mind and able to make decisions about my own health. 

1) I have read and agree to the fore going. 

2) That the procedure set forth above has been adequately explained to me by this provider.


      3)That I authorize and consent to the performance of the foregoing services. 

 

For you or someone else?
Signature
Picture1.png

Thanks for submitting!

Picture2.png