The
Heart of Wellness Karina
Konupek
Client's Agreement with the
Alternative and Complimentary
Energy Medicine Practitioner
1- I fully understand that Karina
Konupek; Expert in Energetic Medicine, Master in Bodywork & Body/Mind Re-Patterning, Spiritual Councilor Educator, Rev.,
is not a licensed medical doctor and is not a psychotherapist. Karina Konupek is a complimentary
and alternative medicine (CAM) practitioner. I also understand that diagnosis or treatment for any disease
or health condition is beyond the scope of any alternative or complimentary health practitioner. If I have
any disease, health problem, or health condition, I am now being advised to seek qualified medical advice from a medical physician.
2- I
am here as a client, on this or any subsequent visit, solely on my own behalf and not as an agent for federal, state, or local
agencies on a mission of entrapment or for any investigative purpose.
3- I understand that the above named practitioner teaches
clients how to build their own health through training in the effective use of life-style modification, pollution, clean air,
pure water, proper foods, rest, exercise, meditation, goal orientation, positive mental attitudes, stress reduction techniques.
As well as modifying physical, spiritual, social, and economic factors affecting over-all health.
4- The
use of exercises, finger pressure, thumb pressure, massage, rapid stretching, tapping, or movements demonstrated on the body of the client are examples which can be performed by the client in the privacy of his/her
own home. Demonstrations for muscle tone or circulation of vital life force energy (as defined by acupuncturists) for greater
fitness levels are NOT to be construed as treatment for any disease or health conditions.
5- Recommendations,
suggestions, and references to meals, menus, or nutritional supplements are for body building,
increasing stamina and energy, and general health maintenance and do NOT involve any diagnosing, prognosticating, or prescribing
for the treatment of any disease or health condition.
6-
I understand that Karina Konupek is dedicated to informing clients how to help themselves
attain better health with emphasis on education and self care. The body-mind-spirit philosophy of holism is not universally
accepted nor recognized. Agencies considered as health authorities may not agree with holistic approach, where clients must
shoulder responsibilities for their own health. Educating clients in holistic health may be considered an inexact science
with many variables. Results from life-style changes are neither constant nor predictable.
7- I have read and understand what
is written above. My signature signifies that I agree to retain the above
named Holistic Health Practitioner to educate me through lecture, testing
evaluations, and demonstrations, in methods available for me to help myself to improvement of my over-all health.
Date:_______________
Client’s signature:________________________________
Print Name:_______________________________________________________
Parent/Guardian's signature:___________________________________________
Address:_____________________________________________________
Telephone:__________________________________
E-mail:______________________________________
Date of Birth:___________________________
Who referred you to us:_________________________
A copy of this Declaration will be kept on file at the
Health Care Providers office or place of business.
