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Client Intake & Liability Form

Please fill out the following form in order to participate in holistic therapy sessions

By completing this form, you acknowledge that you understand Amanda Blain is not a licensed medical professional, nor is she a licensed mental health care provider.

By completing this form, you acknowledge that Amanda Blain operates independently as an alternatively trained and educated trauma-informed holistic therapist and clinical herbalist offering support on matters of the psyche, body, and spirit. 

I certify that I have completed my initial consultation with Amanda Blain, holistic clinical therapist and herbalist, and have agreed to receive private sessions which would include the application of a trained and skilled lens of clinical Traditional Chinese Medicine and Ayurvedic assessments and holistic clinical herbalism, yogic psychology, meditation and ritual, and functional and therapeutic movement as a means to address the issues discussed on our call. 

I understand that Amanda Blain is not a licensed mental health or medical professional, and that her expertise in the holistic therapeutics comes from private apprenticeships with body-centered psychotherapists and mind-body science researchers, certifications in Primal Vinyasa®, Primal Therapeutics®, applied herbalism, Tantric Hatha yoga, ongoing training in Intrinsic Health® and psych education through Sensorimotor Psychotherapy®, Peter Levine's program in Healing Trauma, and continuing education courses through the National Institute for the Clinical Application of Behavioral Medicine. 

I understand that it is my responsibility to seek the advise of a licensed mental health or medical professional should I encounter concerns or complications with my mental or physical health. 

I understand that classes and sessions with Psyche Body Soul include physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I will continue to breathe smoothly. I assume full responsibility for any and all damages, which may incur through participation in sessions with Amanda Blain. 

My sessions with Amanda Blain sessions are not a substitute for medical attention, examination, diagnosis or treatment. By signing, I affirm that a licensed physician has verified my physical condition. In addition, I will make the instructor aware of any medical conditions or physical limitations before classes or sessions. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to participate in Psyche-Body sessions, and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Amanda Blain, Psyche Body Soul.

I have read and fully understand and agree to the above terms of this Client Intake & Liability Form. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law.

Thanks for submitting!

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