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Recreated Life Coaching LLC
Informed Consent Breathwork Practices

Amy Shearer

INFORMED CONSENT

BREATHWORK PRACTICES

RECREATED LIFE COACHING LLC

CLIENT NAME: ____________________ By signing this informed consent disclosure, you acknowledge that you understand what you are reading and agree to the following:

I, ____________________________________ (“CLIENT”), agree to engage AMY SHEARER (“COACH”) to provide certain services, which may include the following holistic practices and techniques:

Breathwork Techniques, which Merriam-Webster defines as “conscious, controlled breathing done especially for relaxation, meditation, or therapeutic purposes”; (collectively referred to as “Breathwork Services” or “Services”).

Although COACH is trained to perform the above Breathwork Services, COACH is not a licensed therapists, medical professionals or other mental health care providers; in order to get medical advice, Client must see a doctor. COACH does not represent the Services as any form of health care or psychotherapy, and despite research to the contrary, by law COACH may make no health benefit claims for said Services. However, these holistic practices are client-centered disciplines, in which COACH is highly trained to assist Client to accomplish their goals, whatever they may be, using the Services described above. Nevertheless, the Services may not be regulated by any government or administrative body. COACH also does not provide any type of therapy services, despite the word “therapeutic” being included in the common definition of breathwork; the type of Services utilized by COACH is non-therapeutic in nature and are designed to supplement treatment and/or advice from licensed medical and mental health providers. Nothing in the Services shall be construed as a substitute for the treatment or advice of a doctor or other licensed medical professional.

Breathwork Disclaimer: COACH does not represent the Services as any form of health care or psychotherapy, and despite research to the contrary, by law COACH may make no health benefit claims for said Services. Client hereby acknowledges that breathwork is not a substitute for medical care, as breathwork neither diagnoses nor treats any medical conditions. Instead, breathwork provides tools for you to complement your medical or other treatments. If any medical symptoms persist or progress, even acutely, you hereby agree to inform your medical provider immediately and seek medical attention. You also hereby agree to notify COACH with any updates to your medical condition after beginning Services and to indemnify COACH of any health issues that may persist or progress whilst working with COACH.

Results Disclaimer: Client also acknowledges that COACH cannot and does not guarantee that implementation of the Coaching Services and Program will provide Client with an ideal resolution and/or perfect life. Throughout the Services, COACH may help Client think through and analyze decisions and assist Client with finding his/her own direction. The COACH may offer her opinion regarding decisions, but it is the responsibility of Client to make the final decision and choose the best option for his/herself. Client also agrees that he/she is solely responsible for any personal and/or professional decisions and indemnifies COACH from any liability regarding said decision. If, at any point during the Services, you feel any adverse effects from any of the Services and/or techniques defined above, you hereby agree to immediately disclose said effects to COACH and your medical service provider.

Confidentiality Statement: Client understands that some of Client’s personal and confidential information may be disclosed to COACH, as COACH administer the Services. Likewise, if Client engages in a group setting for the Services, Client understands that some of Client’s personal information may be disclosed to other clients. Client agrees to keep all other clients’ personal information strictly confidential to preserve the experience for the group. COACH hereby agree to keep all of Client’s personal information confidential and for internal purposes only. However, COACH may use some general statements about Client’s progress as testimonials and on COACH’s website and/or marketing materials. Client may choose to remain anonymous in said testimonials upon prior written consent to COACH.

Emergency Contact: It is possible that certain side-effects, including but not limited to, dizziness and decreased heart rate, may arise when manipulating the breath. In the likelihood that these symptoms or any others persist to the point of an emergency or Client unconsciousness, COACH collects emergency contact information for all clients. You hereby authorize COACH to contact the below representative on your behalf in the event of an emergency during the Services:

Contact Name & Relationship: ________________________________________

Phone Number: ________________________________________

I understand and agree to all of the above terms.

Name: _______________________________________

Signature: ____________________________________

Date: ________________________________________

Informed Consent Holistic Practices

INFORMED CONSENT HOLISTIC PRACTICES

RECREATED LIFE COACHING LLC

CLIENT NAME: ____________________

By signing this informed consent disclosure, you acknowledge that you understand what you are reading.

I, ____________________________________ (“CLIENT”), agree to engage [RECREATED LIFE COACHING LLC] (“COACH”) to provide certain Mindset Coaching Services, which may include the following holistic practices and techniques:

Neuro Linguistic Programming (“NLP”), which is an approach to assist clients to re-pro-gram their thoughts, language, and behavioral patterns to achieve certain desirable out-comes, with a focus on changing neurological programs;
Non-therapeutic Hypnosis (“Hypnosis”), which is defined as the use of hypnosis to incul-cate positive thinking and the capacity for self-hypnosis, which may help client induce positive mindsets and commitment to change;
TIME Techniques, which is a set of tools to help clients eliminate negative emotions of the past and present, with an emphasis on helping Client activate their imagination to create a compelling future.

(collectively referred to as “Mindset Coaching Services” or “Services”).

Although COACH is trained and certified to perform the above Mindset Coaching Services, COACH is not a licensed medical professional or other mental health care provider; in order to get medical advice, Client must see a doctor. COACH does not represent the Services as any form of health care or psychotherapy, and despite research to the contrary, by law COACH may make no health benefit claims for said Services. However, these holistic practices are client-centered disciplines, in which COACH is highly trained to assist Client to accomplish their goals, whatever they may be, using the Services described above. Nevertheless, the Services may not be regulated by any government or administrative body. Nothing in the Services shall be construed as a substitute for the treatment or advice of a doctor or other licensed med-ical professional.

Hypnosis Disclaimer: The Services rendered are held out to the public as “nontherapeutic hypnotism”, defined above. COACH does not represent the Services as any form of health care or psychotherapy, and despite research to the contrary, by law COACH may make no health benefit claims for said Services. Client hereby acknowledges that hypnosis is not a substitute for medical care, as hypnosis neither diagnoses nor treats any medical conditions. Instead, hypno-sis provides tools for you to complement your medical treatments. If any medical symptoms persist or progress, even acutely, you hereby agree to inform your medical provider immediately and seek medical attention. You also hereby agree to indemnify COACH of any health issues that may persist or progress whilst working with COACH. If/when non-therapeutic hypnosis is used during your session, you should ensure that you are fully alert and awake before driving or doing any activity that requires full attention for your safety.

Results Disclaimer: Client also acknowledges that COACH cannot and does not guarantee that implementation of the Coaching Services and Program will provide Client with an ideal res-olution and/or perfect life. Throughout the Services, COACH may help Client think through and analyze decisions and assist Client with finding his/her own direction. The COACH may offer her opinion regarding decisions, but it is the responsibility of Client to make the final de-cision and choose the best option for his/herself. Client also agrees that he/she is solely responsible for any personal and/or professional decisions and indemnifies COACH from any liability regarding said decision. If, at any point during the Services, you feel any adverse effects from any of the Services and/or techniques defined above, you hereby agree to immediately disclose said effects to COACH and your medical service provider.

Confidentiality Statement: Client understands that some of Client’s personal and confidential information may be disclosed to COACH, as COACH administers the Services. COACH hereby agrees to keep all of Client’s personal information confidential and for internal purposes only. However, COACH may use some general statements about Client’s progress as testimonials and on COACH’s website and/or marketing materials. Client may choose to remain anonymous in said testimonials upon prior written consent to COACH.