Client Advisement & Disclaimer Form
I understand that the attending practitioner is not an allopathic doctor (MD), but is a Certified
Biofeedback Specialist and a Licensed Quantum Healer. He is able to identify energetic
imbalances which may represent dis-ease in the body but cannot be referred to as a diagnosis.
All physical issues have energetic components that relate to some form of stress. Therefore, all
stress related issues will be managed with stress reduction and relaxation techniques, pain
management techniques, and methods to help the client improve the quality of life including
detoxification of environmental stressors and enhancement of overall performance.
I understand that the attending practitioner does not provide services that could be defined as
attempting to diagnose, treat, prevent, cure or attempt to cure any medical, emotional, mental or
psychological disease, disorder or condition as defined by allopathic medicine but identifies all
issues as relating to consciousness.
I understand that the attending practitioner does not offer allopathic drugs, surgery, chemical
stimulants or any other conventional treatments, or perform any act that would constitute the
practice of medicine for which a license is required. What is allowed is bringing the client to
awareness, and coaching the client to take responsibility for his/ her own health and initiate self-
I have solicited the attending practitioner’s services in good faith, exercising my free will and
following the dictates of my own conscience which allows me to select what I understand is
most beneficial to my health.
I am fully aware and release the practitioner to do acu-meridian testing, biofeedback testing,
wellness consultation and other stress reduction protocols.
By signing below I acknowledge that I have read and understand all parts of this waiver, that I
have had opportunity to ask any questions with regard to the described procedures, and that I
hereby affirm: I am not here for medical diagnostic or treatment procedures and I am here on
this and any subsequent visit solely on my own behalf.
Date (mm/day/year) ______/______/_______
Client Name (Printed)_____________________________________________
Client Name (Signed)______________________________________________
Code of Ethics
As a Certified Stress Reduction Practitioner and Licensed Quantum Healer, I will:
1. Maintain professional competence by keeping informed of the latest
developments in clinical practice and relevant research.
2. Accurately advertise credential and educational background.
3. Only make claims supported by published scientific evidence when disseminating
information relevant to biofeedback.
4. Take all reasonable precautions to avoid harm to clients, always demonstrating a
concern for the rights, safety, health, welfare, culture and dignity of clients.
5. Provide services without discrimination on the basis of race, creed, age, gender,
sexual preference, national origin, mental, emotional and/or physical disability,
disease, and financial status, social or religious affiliation.
6. Respect the rights of clients to refuse or discontinue services.
7. Maintain professional, goal-related relationships with clients and avoid personal
relationships with clients, other professionals and friends which could interfere
with professional judgment.
8. Refuse services to prospective clients for whom it is judged biofeedback would be
ineffective or inappropriate.
9. Except as otherwise required by law, protect the confidential nature of
information gained from clinical practice.
10. Consult with experienced service providers when additional knowledge or
expertise is required, and refer clients to appropriate service providers when
Date (mm/day/year) _____/______/________
Client Name (Print) ___________________________________________
Client Name (Signature) ____________________________________________