Please fill out and submit the consent form below.

If you'd rather print the form and bring it to your session, download the pdf here.

Blue Lotus Healing Arts
Energy Medicine & Creative Therapeutic Bodywellness
Lori “Lulu” Martin EEM-CP, CMT, CCP
1309 Ynez Place
Coronado, CA 92118
415 887-8653
bluelotushealingarts.blue


CONSENT FORM


Welcome to Blue Lotus Healing Arts. I want you to have sufficient information about the services I provide before we enter into a working relationship together. Please understand that our work together is a collaborative effort to affect positive change in your life. Please fill out & sign this form and email back to me before your session. Let me know if you have questions or concerns.

 

If you are taking a class from me, please send this form with payment to receive confirmation of registration and any materials. I will send out a Zoom link the day of the class an hour before we start. So please before sure to return this at least a day before class.


If coming for a session in person (or via Zoom), please fill out and send this Consent form, the Client Intake form and Five Elements quiz as early as possible, so I can prepare and make the most of our time together.

 

Credentials – I am a certified in many modalities:


Massage Therapist in the state of CA: CMT#52377
Eden Energy Medicine Practitioner
Energy Medicine Yoga Teacher: E500-RYT
Vibrational Sound Healer
Clinical Aromatherapist
Colorpuncturist
Angelic Reiki Master


Description of Modalities:

 

Eden Energy Medicine™ is a modality that recognizes the subtle energy systems which flow through and around the human body, and deeply affect one’s health and vitality. Balancing these energy fields can assist the body in moving towards wellness. I will use muscle response energy testing to assess your body’s energies and then be guided by my findings to facilitate balancing of your energy systems. Additionally, I will teach specific energy exercises to assist you in maintaining the balance we have created in our sessions. Whereas conventional medicine diagnoses and treats symptoms and diseases, Eden Energy Medicine assesses and corrects disturbances in the body’s energies. During a session, you remain fully clothed and before I touch any part of the body that might be considered sensitive, I will ask your permission.

Energy Medicine Yoga has been developed from the Hatha Yoga’s traditional asanas,combined with the beauty and power of Eden Energy Medicine to bring about a deeper harmony and balance to your body, mind and spirit. Group Zoom class on Tuesdays 8:30-10am PST plus private one on one yoga sessions available.

 

Happy Back Yoga is a balanced therapeutic yoga class for spinal health. Group Zoom class on Thursdays 8:30-10am PST plus private one on one yoga sessions available. Vibrational Sound Massage – Himalayan metal singing bowls are played directly on the body to bring about a deep relaxation, aligning heart and mind and soul into a deeper
state of connectedness.

 

Vibrational Raindrop technique – A combination of powerful aromatherapy application with gentle tuning fork acupoint vibration to create deep relaxation, detoxification and more… Several variations available for specific needs.

 

Esogetic Colorpuncture – Precision focused colored light applied to specific acupoints, meridians, and body zones to restore cellular communication and support natural healing processes.

 

Angelic Reiki – Hands on healing. Fosters deep relaxation, pain reduction, harmony and balance infused with Angelic Reiki energy.


Description of Services – My sessions typically last 60-90 minutes, sometimes 2 hours, depending on modality. I am available by phone or email to answer any questions or help you clarify what modality might be best suited to you.

 

Confidentiality – During our time together, anything that is shared is considered strictly confidential. You may instruct me to release information to other health care practitioners, or I may be required to release information if subpoenaed or otherwise legally obligated such as in circumstances where there is clear and imminent danger to yourself or another person. I am required to report to the appropriate authorities if it appears you are a danger to yourself or someone else, or if I have reasonable cause to suspect abuse of a child, dependent adult, or developmentally disabled person. I may
at times consult with other professionals. All consultations will be done in a manner as to protect your anonymity

 

Termination – At any point in our therapeutic relationship I reserve the right to terminate the relationship if I believe that our work together is not productive. I might refer you to another practitioner who is better able to assist you with your unique needs.

 

Payment accepted by check (payable to Lori Martin), Venmo (Lori Martin@bluelotushealingarts), or cash, and is expected on or before the date of the service. If you choose to pay by check, please have your check written out upon arrival.

Cancellation Policy – I require at least 24 hours notification of cancellation. Otherwise, you will be billed and expected to pay for the missed session. CANCELLATIONS MUST BE MADE BY PHONE at 415-887-8653 NOT BY EMAIL.

 

Medical emergencies are, of course, forgiven.

 

Acknowledgement and Consent to Receive Services – I have read and understood the above disclosure regarding the services offered by Lori “Lulu” Martin. I understand she is not a physician, psychotherapist or psychologist and that some of her services may not be licensed in the state of California. I further understand that Lulu is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies. I also understand that Lulu does not claim that her services will heal or cure anyone. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Lori “Lulu” Martin from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). I have consented to use theservices offered by Lulu Martin and agree to be personally responsible for the fees in connection with the services she provides me. That includes full payment for any session or class I miss without providing 24 hours notice.

 

Please indicate your acknowledgement and acceptance of these statements by submitting the form below.

© 2018 Blue Lotus Healing Arts