I acknowledge and agree that:
• Session(s) can and may be beneficial to balance, harmonize, release and heal on all physical, mental, emotional and spiritual levels. I realize the outcome of these treatments, individually and jointly, cannot be predicted with certainty and no guarantee is made regarding any particular result or outcome.
• Prior to the session I will consult with my physician and receive written approval to attend healing sessions if I have metal in my body, suffered concussion/s, have a pacemaker, use an insulin pump, and the like.
• I understand some bodily functions may temporarily be affected as a result of shifting energy within my body and I agree this is a natural occurrence.
• I assume sole responsibility for my own health and for the results of this treatment provided by Trebled Souls LLC and that may affect my health in any way.
• If POUND Rockout Workout is a part of my session, I recognize that I must be in adequate physical and mental health to participate. I understand that POUND Rockout Workout may require intense physical exertion, and I represent and warrant that I am physically fit enough to participate, and I have no medical condition which would prevent my full participation.
• I recognize that POUND Rockout Workout may cause or aggravate a physical injury or medical condition. I understand that it is my responsibility to consult with a physician before my participation. If I have done so, I have taken the physician’s advice.
• I am aware that my participation in POUND Rockout Workout could result in high blood pressure, fainting, heartbeat disorders, physical injury, heart attack or stroke and may aggravate pre-existing injuries. I understand I could experience muscle, back, neck and other injuries as a result of my participation. I understand my physical limitations and I am sufficiently self-aware to stop or modify my participation before I become injured or aggravate a pre-existing injury.
If Pins & Chimes is part of my session, I agree to the following:
1. Acupuncture Consent (Deschutes Acupuncture / Licensed Acupuncturist)
This session includes community-style acupuncture using sterile needles placed on the ear and/or body. Acupuncture is generally considered safe when performed by a licensed practitioner; however, mild side effects may occur, including bruising, minor bleeding, temporary discomfort, numbness, tingling, or dizziness. Participants may be treated in the same room at the same time. You may be seated or lying near other participants. By signing below, you acknowledge that:
• You have been informed about the nature, benefits, and possible risks of acupuncture.
• You have had the opportunity to ask questions and all questions have been answered.
• You consent to receive acupuncture in a community setting.
• You understand you can withdraw consent at any time.
2. Sound & Integrative Wellness Consent (Trebled Souls LLC) Your session includes a sound bath experience—such as crystal singing bowls and other vibrational instruments—along with complementary integrative wellness practices designed to support relaxation, balance, and emotional well-being. You understand and agree that:
• These integrative wellness practices may support physical, mental, emotional, and spiritual well-being, but no specific outcome is guaranteed.
• These services are part of an integrative wellness approach and are not a substitute for medical care. Trebled Souls LLC does not diagnose conditions, perform medical treatment, prescribe medication, or interfere with care prescribed by licensed medical professionals.
• If you have a pacemaker, metal implants, concussion history, insulin pump, or other medical concerns, you agree to consult your physician before participating.
• You assume full responsibility for your own health and any results of this session.
• All information and guidance provided is educational in nature
• I have stated all my known medical conditions to Trebled Souls LLC and if necessary, I will keep Trebled Souls updated on my physical, mental, and emotional health. I acknowledge that Trebled Souls practices for the purpose of providing mental/emotional/physical and spiritual support techniques.
• All information received by me from Trebled Souls LLC is accepted with full knowledge that any action taken by me as a result of the information received is my complete responsibility.
• I will raise any questions or concerns about anything I do not understand in relation to my session/s.
• I release Trebled Souls LLC from all legal liability during my participation in all sessions today and going forward.
• I agree to indemnify and hold harmless Trebled Souls LLC from any loss, cost or liability incurred in defending any claim made by me or anyone making a claim on my behalf, even if the claim is alleged to or did result from the negligence of Trebled Souls LLC.
Liability Release: I release, indemnify, and hold harmless Deschutes Acupuncture and Trebled Souls LLCs and its practitioners from any liability, claims, or demands arising from your participation, including those alleged to result from negligence.
• All information discussed in all session(s) is confidential and will not be shared with any person(s) outside of session(s) without consent from me.
Teen Wellness Program: Teen/participant and Parent/Guardian recognize and agree to the following;
• Confidentiality Agreement: Program discussions with participants will remain private and confidential to foster a safe environment.
• Safety Exception: Confidentiality may be broken if participant shares intentions to harm themselves or others.
• Parental/Guardian Acknowledgment: Parents or guardians understand and agree to this confidentiality policy, including the safety exception.
• Teen Participant Consent: Teens agree to participate openly while understanding the program's privacy and safety boundaries.
• Legal Compliance: Disclosure of sensitive information will adhere to legal and ethical obligations regarding harm prevention.
Healing and medicine are two separate disciplines. Crystal singing bowls, tuning forks, reiki, intuitive work, and the use of any tools such as, but not limited to, tuning forks, a PEMF/Infrared ray/Photon/Negative ion mat are arts of healing, not the practice of medicine. In the case of any serious medical ailment or condition, you should always consult your physician for advice.
Trebled Souls LLC practitioners do not diagnose, perform medical treatment, make any medical claims, offer any guarantees, prescribe remedies or medication, or interfere with any form of treatment prescribed by a licensed medical professional.
Payment is required at time of visit via WixPay and/or Venmo.
If you are unable to keep your appointment, please provide 24 hours notice of the cancellation. If you miss your appointment, cancel or change your appointment with less than 24 hours’ notice, a 100% session fee will be applied.
I have read all the above. By signing below, I confirm that I have read, fully understand, and accept and agree to all its terms and conditions. I am willing to proceed with the session(s).
