Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Phone *

(###)

###

####

1. Which session format calls to you? *

Check all that apply. Sessions are done consecutively in one day.

2.5 hr Intensive

5 30 min sessions (shared as a barn package)

Not sure

2. Has your horse experienced any trauma in the past year? *

Yes

No

4. Have you experienced any trauma in the past year? *

Yes

No

8. Sign up to receive inspiring updates and a complimentary e-book *

We respect your privacy

Yes

No

9. Liability Waiver *

GENERAL I understand that Samhara Energy Medicine is a stress reduction and relaxation technique. I acknowledge that sessions administered are only for the purpose of helping me relax and to relieve stress. Samhara Energy Medicine Practitioners do not diagnose conditions, nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment I may have. I also understand the body has the ability to heal itself, and to do so complete relaxation is often beneficial. Long-term imbalances in the body require multiple sessions to allow the body to reach the level of relaxation to bring the system back into balance. I understand and believe that self-improvement requires commitment on my part, and that I must be willing to heal if I am to receive the full benefit of Samhara Energy Medicine. I acknowledge my commitment to my self-improvement process. I recognize that a Samhara session program must be followed to be truly effective, just as prescribed medication is only effective if taken as directed. Refunds Purchases are non-refundable and non-transferable. Arrival I am not able to take appointments more than 5 min early. For late arrivals, you will have my full attention for the remainder of your slot. Confidentiality Your confidentiality is guaranteed, with only four exceptions:  1.    If I believe that disclosure is essential to prevent physical injury to yourself or others. 2.    If I am of the opinion that a minor is in need of protection from abuse or neglect. 3.    If my records are subpoenaed by court order. 4.    A client reports misconduct of another health practitioner. PRIVATE SESSIONS Payment For in-person sessions, credit card, email transfer or cash is accepted. For phone sessions, payment is accepted by email transfer, credit card or Paypal. HST is included in prices listed. For late payments, you will have 7 days to resubmit your payment. After 14 days, a $10 late fee will be charged. Cancellation 48 hours notice is required for cancellations or changes. The full session fee will be charged if less than 48 hours notice is given. Programs If on a payment plan, sessions are scheduled at regular intervals corresponding with the payment dates or later. Payment plan intervals cannot be extended once a program has begun. Extra Time Pending schedule availability, we can extend a session to fully meet your needs. After a 5 min grace period, the extra time will be pro-rated. Support Calls If a check-in call is needed for additional support between sessions, this can be arranged. If you are mid-program, calls are billed by the minute on a pro-rated basis. Calls outside of a completed program are billed at the regular rate of $275 per hour. WAIVER, RELEASE & INDEMNITY In consideration of Shelly Burton or qualified practitioners, agreeing to provide me with energy medicine treatments as specified above, I for myself, my heirs, my executors, administrators, successors, and assigns, hereby release, waive and forever discharge Shelly Burton and Shift Point Inc and their directors, officers, shareholders, affiliates, associates, employees, agents, servants, contractors, representatives, successors, and assigns ("the Staff") of and from all claims, demands, damages, costs, expenses, actions and causes of action, whether in law or equity, in respect of death, injury, allergic reaction, illness, physical discomfort, loss or damage to my person or property however caused, arising or to arise by reason of the energy medicine treatments, whether as a participant or otherwise, whether prior to, during or subsequent to the energy medicine sessions or events, and notwithstanding, the same may have contributed to, or occasioned by, the negligence of Shelly Burton and Shift Point Inc or their staff. I further hereby undertake to hold and save harmless and agree to indemnify Shelly Burton and Shift Point Inc or their Staff from and against any and all liability by any of them as a result of, or in any way connected with, the energy medicine treatments. If you are under the age of eighteen, please contact us at connect@shellyburton.com as this waiver must be signed by a parent or guardian. By ticking the box below, I acknowledge having read, understood and agreed to the above liability waiver, release and indemnity and I warrant that I am physically, mentally and emotionally fit to engage in energy medicine sessions and events.

I agree to the Samhara Energy Medicine liability waiver