Consent Form

Consent Form

PLEASE READ AND ACKNOWLEDGE YOU UNDERSTAND THE FOLLOWING BY COMPLETING FORM BELOW:

I understand the service provided by Karen Pangelinan of Consecrated Living is deemed holistic and not meant to replace the services of a licensed healthcare professional.

It is my duty and responsibility to disclose my participation with Karen Pangelinan of Consecrated Living to any healthcare professional I am also working with.

I take full responsibility for all my participation and actions while working with Karen Pangelinan.

This includes, but is not limited to: my physical, emotional, and psychological wellbeing. I will not hold Karen Pangelinan or Consecrated Living liable for any loss or injury I may incur from my interpretation of the service she provides.

Not all methods, personalities and perspectives are aligned. Karen Pangelinan operates on the basis of goodness of fit. This goes both ways. Those people choosing to work with Karen Pangelinan need to discern goodness of fit for themselves.

All parties are subject to deciding goodness of fit or alignment at any time.

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

E-mail *

Skype Name:

Is there a certain thing that brought you before us?

Date *

Month Day Year

Please note, our cancellation policy allows two cancellations within a year if notice is given at least 24 hours prior to appointment time. Any additional cancellations within that same year will not be refunded.

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