Client Agreement and Disclosure Statement
The Colorado Natural Health Consumer Protection Act requires that all practitioners of “complementary and alternative health care services” give clients a plainly worded written statement that includes items I-V below. Please check the box below each item to indicate that you have read and understand. Thank you!  
Sign in to Google to save your progress. Learn more
Email *
(I) CONTACT INFORMATION: My name is Tekla Cook Ayers, I am the owner of Tekla C. Ayers, Luz de la Luna, LLC. My contact information is: 1300 Plaza Court North Suite 202, Lafayette, CO 80026 Phone: 301-741-0211 Email: tekla@teklacayers.com  Website: teklacayers.com *
Required
(II) ABOUT Tekla C Ayers, Luz de la Luna, LLC: I offer my services as a complementary and alternative health care practitioner under Colorado’s Natural Health Care Consumer Protection Act. I work with clients in a number of areas, including but not limited to: -----*mind/body/spirit awareness and connection *life transitions *clearing intergenerational patterns stemming from codependency and addiction *overall health through energetic and spiritual wellness. My goal is to support clients to align with their highest potential using Intuitive Reiki, to help clients see new possibilities by clearing and balancing energy in the energetic body (mind/body/spirit). My focus is to work with the whole person, using a variety of complementary and alternative medicine (CAM) approaches, with Intuitive Reiki as the main modality, including past-life and aura readings, incorporating guided meditation and daily mindfulness practices. Intuitive Reiki helps clients to release energy and balance the energetic body so the mind/body/spirit can work to its highest potential. Through our work together, I support the client to see the connection and impact of how thoughts, beliefs, and emotions can influence health and well-being. The work I do with a client is a partnership, and I request that the client fully participate in their growth, and that we have an open line of communication. I will share tools such as meditation and ways to set energetic boundaries, to practice daily in-between sessions. I may also suggest working with another practitioner to improve the client’s transformation and healing process. *
Required
ADDICTION and CODEPENDENCY: I am here to support people affected by the family pattern of addiction, and those who have strong recovery from addiction themselves. If you are struggling with addiction to a substance, I am able to support you as a supplemental support to your recovery. From experience, I can support you if you are actively working on your recovery with resources beyond our work together. I request that you are open and honest with me around addiction in your family so I can best support your growth and healing. *
Required
GROWTH PERIODS: As we work together, it is important to know that energetic healing is a process that can bring many benefits to you on the mind/body/spirit level. These sessions are non-invasive, and it is possible to experience growth periods. These are times during your healing that you may experience some physical and emotional unease, which can be perceived as negative. Growth periods can range from feeling down or more negative, to physical unease. I am here to support you every step of the way and to ride the waves of transformation. You agree to promptly inform me and keep me posted if you experience these growth periods, and though you may not be practiced at reaching out for support, recognize that I am here to support you. *
Required
While working together, you understand that I am not “diagnosing” or “treating” the physical body, which is the domain of the medical field. The services I offer do not replace the services of health care professionals or health care practice. You agree that it is your responsibility to contact healthcare/mental health professionals if you need further support. You understand I may suggest you contact your healthcare/mental health professional if I believe it will benefit your healing. You understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing any of your health care professionals or using prescribed medication. *
Required
(III) EDUCATION and EXPERIENCE: *MA Applied Healing Arts, Tai Sophia Institute (Maryland University of Integrative Health) *Usui/Holy Fire and Karuna Reiki Master Teacher *Reverend from the Church of Inner Light, CO- Intuitive Development and Self-Healing Program Graduate *BS Ecology and Evolutionary Biology *Science and Environmental Educator, Yoga Teacher, Yoga of 12 Step Recovery Leader, Birth and Postpartum Doula *
Required
(V) INSURANCE: I am covered by Great American Alliance Liability Insurance.  You are receiving sessions from me at your own risk. *
Required
(VI) FEE SCHEDULE: Information about packages, classes, and fees are on my website at teklacayers.com  *
Required
(VII) CANCELLATION and PAYMENT POLICY: Unless other arrangements have been made in advance, payment for your session is due at the time of or prior to service. Invoicing through Venmo, Zelle, PayPal, cash or check accepted. 24 hours notice is required when cancelling an appointment. If you cancel with less than 24 hours notice or fail to come to your scheduled session, you agree to pay for the session in full. *
Required
(VIII) CONSENT FOR TREATMENT: I consent to the treatment described above. I understand that Intuitive Reiki sessions for wellness, transformation and spiritual growth are not a replacement for licensed medical or mental health care. No guarantees have been made to me regarding cures or improvements. *
Required
(IX) CONFIDENTIALITY: I understand that all issues related to my sessions will be kept in confidence. *
Required
By checking all the boxes above, and by filling out your contact info below, you acknowledge you have received the information described in Paragraph (a) of Subsection 7 of Colorado’s Natural Health Care Consumer Protection Act all of which is provided in this Client Agreement and Disclosure Statement. Per Colorado law, I will keep an original signed copy of this Client Agreement and Disclosure Statement in my records for at least two (2) years. *
Required
Name (First & Last) *
Today's Date *
MM
/
DD
/
YYYY
Address *
Phone number *
Email address *
Thank you for taking the time to read this form and complete the information. I look forward to working with you! Please leave any info you would like below or contact me with any questions. With Gratitude, Tekla
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Tekla C Ayers. Report Abuse
Google Forms