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Adult Client Consent Form

Terms and Conditions for PSYCH-K® Sessions

1. About PSYCH-K®

The Practitioner provides PSYCH-K® sessions designed to support positive change, personal development, goal achievement, and the transformation of limiting beliefs through the PSYCH-K® process. Sessions may incorporate a variety of techniques intended to support emotional, mental, and physical wellbeing.

PSYCH-K® is a complementary wellbeing process. It is not intended to diagnose, treat, or cure any medical or mental health condition and is not a substitute for medical, psychological, psychiatric, or other regulated healthcare.

2. Informed Consent

I voluntarily consent to participate in PSYCH-K® sessions with the Practitioner.

I understand the nature and purpose of PSYCH-K® and acknowledge that my participation is entirely voluntary. I understand that I am free to pause or end a session at any time.

3. Session Details

  • Sessions last approximately 60 minutes.

  • Sessions are conducted online via WhatsApp, Google Meet, or Zoom, depending on preference.

  • Payment is required before the session.

  • Once payment has been made, refunds are not available.

4. Cancellation Policy

  • Cancellations or requests to reschedule must be made at least 24 hours before the appointment.

  • Appointments cancelled with less than 24 hours' notice, or missed without notice, will be charged at the full session fee.

5. Confidentiality

The Practitioner respects the confidentiality of all information shared during sessions.

Information disclosed during sessions will remain confidential except where the Practitioner believes there is a risk of serious harm to you or another person, or where disclosure is required by law.

6. Client Responsibilities

I confirm that:

  • The information I have provided is accurate and complete to the best of my knowledge.

  • I understand that I am free to stop or pause a session at any time.

  • If I am receiving medical, psychological, psychiatric, or other healthcare treatment, I will consult with my healthcare professional where appropriate before participating in PSYCH-K® sessions.

  • I will continue any recommended medical or mental health treatment and understand that PSYCH-K® is intended as a complementary wellbeing approach and not a replacement for professional healthcare.

Liability Waiver: I agree to release and hold harmless the Practitioner from any claims, liabilities, losses, or damages arising from or related to my voluntary participation in PSYCH-K® sessions, except where liability cannot legally be excluded.

Amendments: The Practitioner reserves the right to amend these Terms and Conditions at any time. Clients will be notified of any changes before their next scheduled session.

Acceptance of Terms: By scheduling and participating in PSYCH-K® sessions, I acknowledge that I have read, understood, and agree to these Terms and Conditions.

7. Practitioner Responsibilities

The Practitioner does not provide medical, psychological, psychiatric, or legal advice.

No specific results or outcomes can be guaranteed, as each individual responds differently to the PSYCH-K® process.

8. Acceptance

By signing below, I confirm that:

  • I have read and understood this consent form.

  • I have had the opportunity to ask questions.

  • I voluntarily consent to participate in PSYCH-K® sessions.

  • I understand the nature, purpose, and limitations of the service being provided.

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Parent/Guardian Consent Form

Terms and Conditions for PSYCH-K® Sessions

1. About PSYCH-K®

The Practitioner provides PSYCH-K® sessions designed to support positive change, personal development, goal achievement, and the transformation of limiting beliefs through the PSYCH-K® process. Sessions may incorporate a variety of techniques intended to support emotional, mental, and physical wellbeing.

PSYCH-K® is a complementary wellbeing process. It is not intended to diagnose, treat, or cure any medical or mental health condition and is not a substitute for medical, psychological, psychiatric, or other regulated healthcare.

2. Consent for a Minor

I confirm that I am the parent or legal guardian of the child named below and that I have parental responsibility for them.

I give my informed consent for my child to participate in PSYCH-K® sessions with the Practitioner.

I understand that, where appropriate, my child's views and willingness to participate will also be respected throughout the process.

3. Session Details

  • Sessions last approximately 60 minutes.

  • Sessions are conducted online via WhatsApp, Google Meet, or Zoom, depending on preference.

  • Payment is required before the session.

  • Once payment has been made, refunds are not available.

4. Cancellation Policy

  • Cancellations or requests to reschedule must be made at least 24 hours before the appointment.

  • Appointments cancelled with less than 24 hours' notice, or missed without notice, will be charged at the full session fee.

5. Confidentiality

The Practitioner respects the confidentiality of all information shared during sessions.

Where appropriate, the child will be offered a confidential space to participate. However, confidentiality may be limited where the Practitioner believes there is a risk of serious harm to the child or another person, or where disclosure is required by law.

6. Parent/Guardian Responsibilities

I confirm that:

  • The information I have provided is accurate to the best of my knowledge.

  • I understand that my child is free to stop or pause a session at any time.

  • If my child is receiving medical, psychological, or psychiatric treatment, I will consult with their healthcare professional where appropriate before arranging PSYCH-K® sessions.

  • I will continue any recommended medical or mental health treatment and understand that PSYCH-K® is intended as a complementary approach.

  • Liability Waiver: The Client agrees to release and hold harmless the Practitioner from any and all claims, liabilities, or damages arising from or related to the sessions. The Client acknowledges that they are participating in the sessions voluntarily.

  • Amendments: The Practitioner reserves the right to modify these Terms and Conditions at any time. Clients will be notified of any changes prior to their next scheduled session.

  • Acceptance of Terms: By scheduling and participating in PSYCH-K® sessions with the Practitioner, the Client acknowledges that they have read, understood, and agreed to these Terms and Conditions.

 7. Practitioner Responsibilities

The Practitioner does not provide medical, psychological, psychiatric, or legal advice.

No specific results or outcomes can be guaranteed, as every individual responds differently to the PSYCH-K® process.

8. Acceptance

By signing below, I confirm that:

  • I have read and understood this consent form.

  • I have had the opportunity to ask questions.

  • I voluntarily consent for my child to participate in PSYCH-K® sessions.

  • I understand the nature and limitations of the service being provided.

Young person's full date of birth
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Year
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Acupuncture and Cupping Consent Form

Do you have any of the following:

Please read this information carefully and ask your practitioner if there is anything that you do not understand.


What is acupuncture?

Acupuncture is a form of therapy in which fine single-use, sterile, disposable needles are inserted into specific points on the body.  Acupuncture is generally very safe. Serious side effects are very rare.

Other side effects:

  • drowsiness occurs after treatment in some patients.  If affected, you are advised not to drive;

  • minor bleeding/bruising occurs in about 3% of treatments;

  • pain during treatment occurs in about 1% of treatments;

  • existing symptoms can get worse after treatment (< than 3% of patients). Tell your acupuncturist about this - it's usually a good sign;

  • fainting can occur in certain patients, particularly at the first treatment.

Is there anything your practitioner needs to know?

Apart from medical details, it is important to let your practitioner know:

  • if you have ever experienced a fit, faint or funny turn;

  • if you have a pacemaker or any other electrical implants;

  • if you have a bleeding disorder;

  • if you are taking anticoagulants or any other medication;

  • if you have damaged heart valves/have any particular risk of infection.

Statement of Consent: I confirm that I have read and understood the above information, and I consent to having acupuncture treatment. I understand that I can refuse treatment at any time.  I understand that the practitioner will not be able to diagnose any health problems and will deliver complementary therapy based on the information I give.  I understand that the treatments offered are not a substitute for medical advice and treatment.  I understand that the practitioner can refuse to continue therapy at any time.


What is cupping?

Cupping is a therapy that applies negative pressure on the skin using glass, plastic, or silicone cups. The suction created by these cups stimulates and increases blood flow, which can help relieve joint and muscle pain, reduce inflammation, accelerate recovery, increase the function of the lymphatic and circulatory systems and increase overall relaxation and well-being.

Common Contraindications for Cupping Therapy

  • Blood clots                        

  • Bleeding disorders           

  • Bruise easily 

  • Haemophilia

  • Infections                          

  • Acute skin conditions                   

  • Burn / rash           

  • Skin lesions

  • Cancer                                

  • Areas of herniation          

  • Hematomas

  • Phlebitis / Varicose veins          

  • Impaired sensation                  

  • Oedema / lymphedema              

  • Certain medications                   

  • Deep vein thrombosis

  • Epilepsy                              

  • High blood pressure        

  • Open wounds              

  • Suspected haemorrhage

  • Diabetes with complications or an acute infection

  • Taking anticoagulant medication/blood thinners for example, Aspirin

  • Severe chronic disease such as heart disease

  • You are pregnant/are within 6 weeks of giving birth/are menstruating

  • Lymphedema or Anaemia

  • Recently given blood or undergone a medical procedure

Please Read Each Item Below

  • My therapist has informed me of the contraindications of cupping therapy, and I have provided my therapist with an accurate and complete medical history.

  • I have no contraindications for cupping therapy.

  • I agree to communicate to my therapist any physical discomfort experienced during the session.

  • I understand that the vacuum formed by cupping may result in marks being left on my body

  • I release the therapist from all liability for any harm that may unintentionally result from this treatment

  • I further understand that massage and cupping therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that complementary therapists do not diagnose disease, and nothing said during the treatment should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken

I have read and understood the consent form and wish to proceed with the session.
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