Intake Form I am a New Client I am an Existing Client Name(Required) First Last Date of Birth(Required) Month Day Year Age(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)Emergency Contact(Required) First Last Emergency Contact Email(Required) Emergency Contact Phone(Required)How did you find us?(Required)Agreement for Spiritual Services(Required) I agree to the following terms:Agreement for Spiritual ServicesThis agreement (the “Agreement”) is made and entered into by and between Explore the Sea of Qi, LLC (the “Company”), a provider of spiritual-related services as outlined hereinbelow, and the Undersigned (the “Client”), who, by signing below, acknowledges and agrees to the terms and conditions set forth herein.By signing this agreement, the client affirms that they are voluntarily engaging the Company to provide such services and acknowledges that they have read, understood, and agreed to the terms and conditions contained herein.List of ServicesBy executing this agreement, Client agrees to engage the Company and pay the related service fees for spiritual-related services, as requested, which may include (but are not limited to) the following:Spiritual DirectionCoaching (Gallup-Certified Clifton Strengths Coach)Grief SupportMinisterial ServicesSpirit ArtMeditationSpiritual HealingIndividual Workshops/ClassesThe Company and its representatives are ordained ministers or healers from accredited or recognized seminaries and institutions. Services rendered include weddings, funerals, christenings, dedications, home, land, and office blessings, non denominational ceremonies, and special life celebrations. Company’s representatives may also hold additional certifications such as Reiki practitioner, Intuitive Practitioner, Spiritual Healing Practitioner, Certified Medium, Coach, Spiritual Director, or grief support. Not all Company representatives hold all certifications referenced and may be limited in their ability to perform certain Services based on those certifications held by Company representatives available at any given time. Additional Services may be recommended by the Company or its representatives. In light of this, depending on your needs and preferences, any number of these services, and others, may be provided as is appropriate, per our mutual consent and discussion. It is understood that neither the Company, nor its employees, representatives, agents, or assigns, has any authority or a license to prescribe, recommend, or enforce any advice, action, medication, activity, or direction in any area of your life, as these decisions are fully your own. The Company does not employ medical professionals and is not trained to recognize, diagnose, or treat any medical, psychological, or psychiatric conditions. Clients are strongly encouraged to seek guidance from appropriately licensed professionals for any medical, psychological, legal, real estate, or financial concerns, as none of these areas fall within the scope of the Company’s services. By signing this Agreement, the Client acknowledges and agrees that all services provided by theCompany are for personal development, spiritual guidance and healing, and educational purposes only.The Client fully understands and accepts that the Company does not employ medical professionals, does not diagnose or treat medical, psychological, or psychiatric conditions, and is not trained to recognize such issues. The Client further acknowledges that the Company’s services are not a substitute for medical, psychological, legal, financial, or other professional advice, and the Client has been encouraged to seek assistance from appropriately licensed professionals for such concerns.I acknowledge that in order to facilitate the level of healing that is desired, I may require multiple sessions commensurate with my unique, individual circumstances. I also understand that there are no guarantees as to the results or progress to be made, only that I will, to the best of my ability, endeavor to accomplish the objective of my sessions.The Client expressly agrees to release, indemnify, defend, and hold harmless the Company, its owners, employees, representatives, agents, and assigns (collectively, the “Released Parties”) from any and all claims, liabilities, damages, demands, costs, or expenses, including but not limited to personal injury, emotional distress, or financial loss, arising directly or indirectly from the Client’s participation in the services provided.The Client further understands and agrees that the Company reserves the right to terminate services at its sole discretion if it determines that the Client’s needs are medical in nature or otherwise outside the scope of the Company’s expertise. The Client voluntarily assumes all risks associated with participating in the Company’s services and waives any and all claims against the Released Parties.This Release of Liability is binding upon the Client, the Client’s heirs, successors, assigns, and legal representatives.By signing below, the Client acknowledges that they have read, understood, and agreed to the terms of this Release of Liability.Confidentiality (HIPPA)The Client acknowledges and agrees that the Company, in its role as a spiritual advisor, does not fall under the definition of a “Records Custodian” as defined under the Health Insurance Portability and Accountability Act (HIPAA) or any other medical records laws or regulations. As such, the Company is not subject to HIPAA’s provisions regarding the collection, storage, or disclosure of protected health information (PHI).Notwithstanding the foregoing, the Company is committed to maintaining the highest standards of confidentiality. The Company agrees to keep all information obtained in the course of providing services in the strictest confidence and shall not disclose any such information to any third party without the express written consent of the Client, except as required by law.The Company reserves the right to disclose information when it reasonably believes that such disclosure is necessary to protect an individual or animal from a specific and credible threat of harm. In such circumstances, the Company may, at its sole discretion, contact appropriate professionals, including but not limited to medical or mental health professionals, state or federal law enforcement, or other relevant authorities, to ensure the safety of those involved.This confidentiality obligation shall survive the termination of this Agreement.FeesAll fees for services provided by the Company shall be charged either at an hourly rate or on a per- occurrence basis, as set forth in the Schedule of Services, which may accompany this Agreement. Fees vary according to the services rendered. Standard hourly rates of $150.00 per hour for individual sessions apply. Special group rates, events, and special services will be individually quoted and invoiced on a case by case basis. The Client further acknowledges that all fees are subject to change at the discretion of the Company, with prior notification.Payment PolicyPayment is due before or at the time of service. The Company accepts cash, checks, credit cards, and payments via PayPal. The Client acknowledges that the services provided by the Company are generally not covered by insurance, and the Client’s obligation to pay for services is not contingent upon insurance coverage or reimbursement. Upon request, the Company will attempt to provide documentation needed for the Client to seek insurance reimbursement. However, the Company reserves the right to refuse requests that are onerous, overly burdensome, or outside the scope of its standard administrative processes. Additionally, the Company may charge the Client an administrative fee for any significant efforts required to comply with such requests.Cancellation PolicyAppointments canceled 24 hours or more in advance will have no cancellation fee. However, appointments canceled within less than 24 hours are subject to the agreed-upon hourly rate for the number of hours of service scheduled.Advisory on Consultations with Spiritual PractitionersClient acknowledges that any consultation with a spiritual medium, intuitive advisor, or similar practitioner is undertaken solely for personal reflection, entertainment, or spiritual guidance and not as a means to obtain legally actionable predictions or guarantees regarding future events, financial matters, legal decisions, or personal relationships.Client further understands that under applicable law, it is unlawful for any person to engage in fortune- telling, spell-casting, or similar practices for financial gain under the pretense of predicting future events, influencing luck, recovering lost or stolen property, or altering personal or business outcomes. This agreement does not endorse or authorize any such unlawful activity.By entering into this agreement, the Client affirms that any engagement with a spiritual practitioner is conducted voluntarily and without reliance on any representation of supernatural influence over real- world events. The Client assumes full responsibility for any personal decisions made as a result of such consultations.Consent and AgreementBy signing this Agreement, I, the Undersigned Individual, freely and willingly consent to participate in the services rendered by the Company. I acknowledge that I have read, understand, and agree to be bound by the terms and conditions set forth in this Agreement.I further acknowledge that while the Company and its representatives may utilize various spiritual tools as part of their services, I am NOT seeking, directly or indirectly, to have my “fortune told” or to receive predictions of future events in violation of Pennsylvania law. I understand that any insights or guidance provided are for personal reflection and spiritual exploration only and that I am solely responsible for my own decisions and actions.I expressly waive and release the Company, its owners, employees, representatives, agents, and assigns from any and all claims, liabilities, or damages arising from my participation in these services. I acknowledge that the Company makes no guarantees, warranties, or assurances regarding the accuracy, effectiveness, or outcomes of the services provided.By signing below, I affirm that I am entering into this Agreement voluntarily, without coercion, and with full understanding of its terms.Signature(Required) Name(Required) First Last Email(Required) Acknowledgement(Required) I confirm that I am an existing client and have previously filled out an intake form that is required before scheduling my session. "Art is the language of the soul, a bridge between the seen and unseen."
