Intake: Personal and Health Background

This form has been given to you to provide valuable information in assisting in your therapy. While sharing most information in this form is voluntary, you must fill out the contact information immediately below, as well as sign and initial the consent at the end of this form, for us to work with you. In addition to personal information, you are asked to disclose current and past medical history protected by the Health Insurance Portability and Accountability Act. As such, you have certain privacy rights in this information and, in compliance with the law, our HIPPA policy is available to you upon request. All information we obtain about you, whether written or shared verbally during session, and whether from you directly or another source, will be held in the utmost confidentiality. We will never share your information, medical or otherwise, without your express written consent and direction, unless otherwise required by law. While providing personal and medical information about you is entirely voluntary, without this information you may impair the progress of your sessions and potentially create risks to your health.

If you have any questions about how to complete this form, how we use your information, or what your rights are regarding your information, please ask your practitioner immediately before signing below.

Thank you!

Stephanie

Basic Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Month

Day

Year

Address(Required)

Street Address Address Line 2 City State ZIP Code

Medical & Emergency Information

Emergency Contact

First Last

Emergency Contact Phone

Medical Conditions

Addictions

Allergies

Anemia

Anxiety Disorders

Arthritis

Asthma

Autoimmune Disorders

Cancer

Chronic Conditions

Claustrophobia

Diabetes

Depression

Eating Disorders

Food Sensitivities

Headaches

Heart Problems

Hypoglycemia

Inner Ear Problems

Joint/Muscle Pain

Neurological Disorders

Pregnancy

Thyroid Disease

Other

Please Elaborate(Required)

Personal Background

Please answer as many questions as you are comfortable sharing.

What is your previous experience with Crystal Therapy?

What issues do you want addressed during Crystal Therapy?

Do you meditate?(Required)

Yes

How would you describe your spiritual beliefs, if any?

Please check all that apply

I have experienced crystal therapy before

I have experienced a Reiki session before

I have had an energy balancing session before

I have used holistic remedies before

I know about chakras

I have a spiritual path that I am consciously following

I have difficulty adjusting to new situations

I have experienced trauma

I am generally uncomfortable with touch

I am generally uncomfortable expressing myself

I love myself

I accept myself

I am comfortable expressing myself

I feel like I belong

Consent and Release of Liability

Consent and Release of Liability Content

By signing below, you understand and agree to the following:

I am requesting the service of Stephanie Benstock, LMT, RMT, ACM/Well From Within - Integrative Healing, for the purpose of assisting me to access my own inner resources of energy therapy so that I may learn to heal myself.
All information I have provided in this Intake and Consent Form is accurate and to the best of my knowledge.
I understand no guarantees or warranties are made to the effectiveness of energy therapy, and take full responsibility for my expectations of the therapy process.
I understand the associated risks of crystal therapy, if any, as explained to me by the practitioner and agree that it is my responsibility to seek any further information I feel I need.
I understand that, while certain medical options may be explained to me in the course of my therapy, these explanations are in no way either a suggestion for medical treatment or any sort of prescription or medical directive, and do not constitute licensed medical advice. I waive any and all remedies I may have based on my own reliance on such information.
I release my practitioner, as well as any of their assistants or related business interests, from any and all liabilities or claims of any nature that may result from my participation in energy therapy, including but not limited to damages from my failure to pursue medical attention from a medical professional, for the exacerbation of any preexisting physical ailments I may have, and by signing here, I agree to all these terms, and further bind my estate, heirs, and assigned to this release of liability.

Consent and Release of Liability Agreement(Required)

I understand and agree to the Consent and Release of Liability.

Client Disclosures

Client Disclosures Content

As a Hibiscus Moon Certified Crystal Practitioner, I would like to welcome you to my practice and provide some information relevant to our relationship and your experience through the energy therapy process.

Crystal Treatment

The purpose of a crystal therapy session is for mental and spiritual well-being. My method of treatment, energy therapy, is an alternative or complement to therapy arts otherwise licensed by the state. We will use a variety of techniques to facilitate well-being and clarity in the moment, while promoting long-term self-reliance through practical techniques to help raise consciousness, clear confusion, recognize intent, and interpret meaning and quell doubt.

If you ever have any concerns about the nature of your treatment, you are free to discuss them with me at any time. As I am committed to monitoring your progress, I ask that you please bring any new information affecting your treatment as soon as practical. You are entitled to stop treatments at any time, with or without reason, and I recommend that you inform your medical provider that you are receiving energy therapy treatment. While I use my best efforts during our sessions, I cannot guarantee any particular outcome as results vary from person to person.

State and Federal Law

I am not a licensed physician, nor are energy therapy services licensed or controlled in most states. As your practitioner, I am responsible for knowing any applicable State and/or Federal laws that may apply to me, and for disclosing those laws to you. Since it is likely that any laws regarding crystal therapy will change over time, I also encourage you to research and stay informed on current laws and to bring any changes to my attention.

Requirements to be a Hibiscus Moon Advanced Crystal Master

In addition to my commitment to a professional code of ethics, I completed a sequence of classes through the certification program and received a passing average grade of 75% or higher on the required corresponding assignments. Further, I was required to perform therapy sessions reviewed by my instructor and clients for effectiveness and professionalism, and otherwise encouraged to continue hands-on training in my practice. I received an Official Certificate of Completion to be qualified to use the letters ACM after my name. If you have not already done so, you may request to see my Certificate at any time or a current list of my other qualifications.

I was certified by Hibiscus Moon on June 9, 2022

Practitioner's Qualifications

In addition to my certification, as well as continuing efforts to educate myself on the techniques used in my practice, my other qualifications include:

NYS licensed massage therapist (2009)
Usui Reiki Master Teacher (2012)

Practitioner's Commitments to You

As a practitioner, part of my certification process through the Hibiscus Moon Certification Process included a commitment to a Code of Ethics that requires professionalism, safety, and consistency in all therapy practices. Thus, in my practice of the Hibiscus Moon Crystal Therapy Method, and as a Certified Crystal Practitioner, I have vowed to always:

Practice methods as taught during my certification and use all precautionary measures;
Only perform massage, acupuncture, or acupressure if licensed to do so;
Preserve client confidentiality, and never share information learned during sessions or intake with others unless required by law;
Abstain from giving any medical diagnoses, interfering with the treatment of a licensed health care provider, or suggesting the use or change of use of any prescription, medication, or treatments;
Actively work on my own therapy and education so as to embody and fully express the essence of crystal therapy in every facet of my life;
Be responsible for the energy I bring into the therapy space and into any transactions as a practitioner, always striving to be positive;
Be open to the continuing process of enhancing my professional qualifications, training, experience, and skills;
Respect and value all energy workers and types of therapy modalities, and refrain from making negative statements about others;
Encourage my clients to heal themselves, and assist them in their personal growth as well as their own crystal practice;
Treat my clients and their physical person with the greatest respect, and never engage in any illegal or immoral activity which hurts them, such as unsolicited touching of their genital area or breast tissue, asking them to disrobe, or sexual comments, jokes or references;
Abstain from the use of drugs or alcohol during all professional activities;
Be truthful in my advertising by openly discussing my training and background, what is offered in a crystal therapy session, the fee that is charged, and the amount of time spent in sessions;
Educate my clients regarding the merit of crystal therapy in conjunction with other medical treatments, and thoroughly explain that it does not guarantee a cure and is not a substitute for medical or psychological treatment, but only a supplement to these treatments.
Learn and obey the most current local, state, and federal laws applicable to my practice.

Practitioner Commitment in Providing Services

The Disclosures made here are accurate to the best of my knowledge and reflect my commitment to your therapy as my client. I will at all times endeavor to abide by the Code of Ethics I have adopted for myself. I will work with you in your energy therapy to reach the goals you have set for yourself and will not interfere with your own personal beliefs or energy efforts. If at any time I feel it necessary or advisable, I will discontinue our therapy practice to prevent any harm to you, to myself as a practitioner, or to my therapy practice. I have made these disclosures voluntarily and, while I make no representation that the information contained herein will remain accurate during the duration of our practitioner-client relationship, I will work within the terms of this disclosure as far as I am able.

Signed,
Stephanie Benstock, LMT, RMT, ACM

Client Disclosures Agreement(Required)

I have read and understand the Client Disclosures.

Client Acknowledgement and Consent to Receive Services

Client Acknowledgement and Consent to Receive Services Content

I have read and understand the above Disclosure about the energy therapy treatment offered and have discussed with my practitioner the nature of the services to be provided. I consent to and affirm all the terms included in this Disclosure, and agree to read all material provided to me regarding my practitioner's practice. I understand my practitioner is not a licensed physician and that energy therapy services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself with a medical doctor. I have consented to use the services offered, and agree to be personally responsible for all fees charged in connection with the services provided to me.

Client Acknowledgement and Consent to Receive Services Agreement(Required)

I have read and understand the Client Acknowledgement and Consent to Receive Services.

Client Signature(Required)