Client Information Be sure you hit submit when you have completed the form. SHN - Client Information Name* First Last Email:* Enter Email Confirm Email Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:* Date of Birth:* Marital Status:* Occupation:* How did you hear about us?* What are the best times to conduct your sessions?*Please check which of the following items you would like support with: Spiritual Exploration Past Life Exploration Grief Nightmares Trauma Suspected Memory Loss Anxiety / Stress Stop Smoking Exam Anxiety Depression Angry Feelings Weight Issues Financial Worries Guilt Feelings Unwanted Habits Alcohol Usage Drug Usage Chronic Pain Relationship Issues Lack of Energy Sleeping Problems Sexuality Low Self-Esteem Shyness Life Purposes Specific Fears If other, please list: Do you have experience with: Guided visualization Meditation Self-hypnosis Day dreaming Have you ever been a participant in: Counseling Therapy Support Groups Coaching Other related support If yes, please briefly describe your experience: (Max length 2500 characters)Are you currently under the care of a health care professional?* Yes No If yes, please explain: (Max length 2500 characters)Are you currently taking any prescription medications?* Yes No If yes, please list:Please share briefly about your spiritual philosophy or beliefs (Optional - Max length 2500 characters)Please share briefly about your background: (Family, relationships, career, etc. - Max length 2500 characters)CELLULAR RELEASE SPECIALIST DISCLOSURE STATEMENT The Sunrise Holistic Network is a group of individuals that are credentialed in various methods and modalities that support the healing and well being of those they serve. Each individual’s training and credentials are unique to the Cellular Release Specialist and will be made available to you upon request. Nothing in the work that is done is considered the practice of medicine. It is strongly recommended that any medical conditions you may currently have be directed to the attention of an appropriate health care professional. Sunrise Holistic Network Cellular Release Specialist agrees to provide client centered services in accordance with their acquired training and experience. Client may be taught the use of technique to achieve states of relaxation, meditation and self-empowerment to assist in achieving goals. Information during your consultation and sessions is confidential. Therefore, the Cellular Release Specialist cannot be forced to disclose information without your consent. There are exceptions to this general rule of confidentiality. These exceptions are based on the client’s safety and the safety of others in the client’s life. If a threat to life is disclosed appropriate action will be taken. All sessions will be conducted over Skype or ooVoo unless the opportunity to be in the same location for a live session arises and is feasible. It is recommended that you have a private and comfortable location for the session and that the use of headphones or earbuds and an adequate microphone available for your sessions. Fees and payment are established by and paid directly to Sunrise Holistic Network. All payment is due in advance of sessions. By clicking the "Submit" button at the bottom of the this page, you are signing electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this electronic form. By completing the "Full Name" and "Today's Date" boxes below, I am confirming that I have thoroughly read, understand and agree to all of the information as written in the Disclosure Statement. Confirm your understanding and agreement to all the terms and conditions listed.Full Name* Today's Date* MM slash DD slash YYYY CLIENT AGREEMENT I understand that the services provided me are for educational and self-improvement purposes only and are not intended as treatment for any mental illness or professionally diagnosed physical condition. I acknowledge that my well-being depends directly on how well I care for myself physically, emotionally, intellectually and spiritually. I recognize that my thoughts, feelings, images and actions have a direct affect on my life. I agree to be an active participant and see myself as a partner in my own transformation. I agree to be on time and to allow at least 24 hours notice should I need to cancel or reschedule. If I am unable to cancel with more than 24 hours notice, I agree to pay $75 cancellation fee. I confirm that I am of legal age to participant in sessions and other services provided by the Sunrise Holistic Network Cellular Release Specialist. I, for myself, my heirs, executors, administrators and assignees, do hereby release Sunrise Holistic Network, The Gabriel Method, Paula Robbins, Jon Gabriel, and any of his/her employees or other participants from all claims of damages, demands or actions whatsoever in any manner arising from and growing out of my participation. By clicking the "Submit" button at the bottom of the this page, you are signing electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this electronic form. By completing the "Full Name" and "Today's Date" boxes below, I am confirming that I have thoroughly read, understand and agree to all of the information as written in the Client Agreement. Confirm your understanding and agreement to all the terms and conditions listed.Full Name* Today's Date* MM slash DD slash YYYY
