Consent for Services

Rebecca Cook LLC

 

Client Agreement for Services, Disclosures & Consent for Body Work, Aromatherapy Massage and Energy Medicine Sessions  

Practitioner Name:  Rebecca Younglove-Cook practicing through Rebecca Cook LLC

Business Location: 5600 Katz Road, Grass Lake, Michigan 49240

Contact: rcookotr@gmail.com 

 

Definition of Body Work, Aromatherapy Relaxation Massage and Energy Medicine

Body Work uses hands-on touch to release soft tissue areas that are tight and/or painful. Wear comfortable exercise clothing as sessions are completed fully clothed.

Aromatherapy Relaxation Massage facilitates nervous-system whole-body relaxation through back massage and hand/feet reflexology massage with a variety of essential oils. The session is completed face down on a massage table with the shirt removed.

Energy Medicine is a holistic integrative approach intended to clear, balance, and energize the human energy system in order to facilitate physical, emotional, mental, and spiritual self-healing. 

Your trained practitioner uses various bodywork and energy modalities with a heart-centered and prayerful intention. God is our ultimate healer and designed our body with self-healing abilities that we cooperate with.

Body Work, Aromatherapy Relaxation Massage, and Energy Medicine is intended to complement and not replace any prescribed medical care. Practitioners do not diagnose conditions or prescribe treatment.

 

Session Information

Body Work or Aromatherapy Relaxation Massage sessions are 50 minutes, in-person, and the fee per session is $120.00. These sessions are scheduled at your home or business (requirements include easy access to carry a massage therapy table, room space to set up the table, ease of parking, safe setting, and privacy for the session). There are no travel fees for distances of 20 miles or less from the business address listed above. An additional travel fee of $25 is charged for distances of 21-35 miles away, with a distance limitation of up to 35 miles from the business address listed above. In special circumstances, sessions may occur at the business location listed above (please reach out to determine if this is a possibility for you and be aware the treatment room is downstairs in a private home where there is no public restroom).  

Energy Medicine sessions are $50.00 per session and are completed on request without in-person requirements.

Rebecca Younglove-Cook and Rebecca Cook LLC is not a provider for any insurance carrier and sessions are on a cash-basis with payment expected prior to or on the date of service. Please note this business does not accept checks or credit cards.

Services, Precautions, Contraindications

Services are founded on a wellness model and do not require a prescription. If you consent to services, you agree that you are of sound mind and agree to be responsible for yourself and for your own self-healing wellness journey. You agree you are willing and able to make a choice to seek additional professional help at your own expense if your symptoms go beyond the self-healing and wellness services offered by your practitioner listed on this form.

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Precautions to in-person hands-on sessions include dizziness, congestive heart disease, decreased sensation, pregnancy, varicose veins, arthritis, pain medications or medications that affect sensation. Please identify if you have any of these precautions and add any additional precautions particular to your situation that we should be aware of (type in none if there are none):

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Contraindications to in-person hands-on sessions include active illness, fever, infection, inflamed areas, recent surgery, pitting edema, blood clots, cranial tumor, healing fracture, open skins areas, bruised swollen areas, areas of joint instability, anti-coagulant therapy, any medications or skin allergies that react with essential oils, recent head injury, aneurysm. Please add any information about any contradictions particular to your situation that your practitioner should be aware of (type in none if there are none):

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Precautions to distance energy medicine sessions and in-person hands-on sessions include active mental/cognitive/spiritual health issues that require professional help. Please indicate if this is applicable to you (and briefly describe) or if not write (none).

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Contraindications to distance energy medicine session and in-person hands-on sessions include a condition that impairs judgement, impacts safety, affects the ability to cope with stress/becoming overwhelmed by it, and/or reduces the capacity for self-healing and self-responsibility in any manner. (write “none” if there are none)

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Appointment Cancellation Policy:

I agree to give a 24-hour notice if it is necessary for me to cancel an appointment. My practitioner reserves the right to charge me for the session if sufficient notice is not given.

 

Covid policy: For your safety and our safety, in-person sessions at the business location cannot be scheduled if you have been in contact with anyone with Covid/Covid symptoms for the previous 10 days or it you have tested positive with Covid or have had Covid symptoms within the previous 10 days. In-person sessions at your home or business location cannot be scheduled if anyone in the home or business has been in contact with anyone with Covid/Covid symptoms for the previous 10 days or if you or anyone in the home or business has tested positive with Covid or has had Covid symptoms within the previous 10 days.

 

Confidentiality:

All client information and records are treated in a confidential manner and no information will be released to anyone without prior written consent, except in situations governed by law.

 

Disclosures:

  • Energy Medicine and Bodywork practitioners do not diagnose conditions or prescribe treatments. 
  • No specific claims will be made by the practitioner regarding results from these sessions. 
  • Goal(s) for our work together will be mutually identified as part of the assessment and clients have input in the goal-setting process.

 

Hold Harmless Clause:

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless, Rebecca Younglove-Cook and Rebecca Cook LLC, from and against any and all claims or liability of whatsoever kind or nature arising out of, or in connection, with my session(s).

 

Client Consent for Sessions:

I have read this document and been given the opportunity to ask questions regarding this document and any sessions I am choosing.

(Place your initials in the box.)

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I take responsibility to inform my practitioner of any changes in my health status including updating my practitioner at least 24-hours prior to any session on any precautions and contraindications.

(Place your initials in the box.)

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Yes, I give permission for hands-on touch in sessions as needed.

(Place your initials in box.)

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Client Name and Complete Address (including city, state, zip code)

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Client date of birth:

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For the Client or Legal Guardian: Typing your name in the box below constitutes your electronic signature acknowledging the information on this form is accurate and correct. Your electronic signature is legally binding and by signing you acknowledge you are legally authorized to do so.

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Are you the client or the client's guardian?

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Date this form was completed.

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