* Date Of Birth

* What's your professional background

* How were you referred ?

* Are you in good health?

* Are you taking any medications, vitamins or herbs ?

* Do you use caffeine or other stimulants ?

* Have you ever worked with any type of counseling?

* Do you meditate?

* Do you have/follow spiritual beliefs and practices?

* Marital status

Are you pregnant?

Please check all the boxes that apply to you

Location and level of pain from 0-10 (0 being nothing and 10 being unbearable )

If you have answered 'YES' to any of the above questions please provide relevant details (such as duration of the problem, current situation and treatments). In addition, please include any other relevant health information..

Please check all the boxes that apply to you below.

Physical

Emotional

Lifestyle

Signature 2 Healing Client Waiver

I, the undersigned, hereby acknowledge my engagement in holistic counseling and natural healing practices. I fully understand that these techniques do not represent, express, or imply any form of medical treatment or diagnosis. I hereby acknowledge that I have been advised to consult with my physician prior to engaging in these holistic practices. I understand that these modalities, which may involve physical movements, emotional work, and energetic healing, are not a substitute for professional medical care.

I understand and acknowledge that the practitioners, Aparna Shah and Divya Shah Waghray, are not licensed medical professionals, such as physicians, psychologists, or psychiatrists. I am engaging with them as a client to receive holistic counseling and therapy, not as a patient for medical treatment.

I have been advised to consult my physician for any medical concerns, and I understand that the practitioners will be happy to provide a referral to medical professionals at my request. I hereby waive all rights to any cause of action against Aparna Shah, Divya Shah Waghray, and Signature 2 Healing LLC, arising from any services provided by them, including all information, techniques, and tools. This waiver also legally binds my agents, assignees, or beneficiaries.

I hereby acknowledge that I am signing this waiver and entering into this agreement voluntarily, of my own free will. I have read, fully understand, and agree to the policies and procedures stated above.

Your information is confidential. It will be used only by Signature 2 Healing LLC and will not be shared with anyone else without your consent.

All information provided will be retained solely by Signature 2 Healing LLC, and will not be released to any other parties without your consent.

ADDRESS​

Signature Healing – Box 1040 Newport
News VA 23601

[email protected]
Aparna Bararia Shah:
(757) 597 – 4533
Divya Shah Waghray:
(574) 370 – 8430

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