Session Form

Name*

First Last

Mobile Phone:*

Email*

Do you prefer to be contacted by email, phone or text?*

email
phone
text

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Emergency contact Number

How did you hear about CORE Energetics?*

Do you have any physical issues or illnesses? Are you on medication or have you been on medication in the past? Have you experienced any physical and/or emotional trauma that we should be aware of? Is there anything else you would like to share about yourself?*

Session Agreement

Please review and sign before you participate in any CORE Energetics sessions or workshops I understand that I am responsible for my health and well-being and that this work does not constitute a medical treatment. I take responsibility for alerting the facilitator to any condition that I may have that needs to be considered when engaging in emotional and physical therapeutic activities. I agree to confidentiality. By signing below, you agree that the facilitator and/or studio owners are not responsible or liable for any injury that may occur during the work-shop. If you have any concerns about your health, please consult a doctor before taking part in a CORE Energetics session.

COVID-19

Please review and sign before you participate in any CORE Energetics sessions or workshops I understand that I am responsible for my health and well-being and that this work does not constitute a medical treatment. I take responsibility for alerting the facilitator to any condition that I may have that needs to be considered when engaging in emotional and physical therapeutic activities. I agree to confidentiality.
I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19. I voluntarily seek services provided by Core London and acknowledge that I could be increasing my risk to exposure to the Coronavirus/COVID-19.
I attest that:
I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
By signing below, you agree that the facilitator and/or studio owners are not responsible or liable for any injury that may occur during the work-shop. If you have any concerns about your health, please consult a doctor before taking part in a CORE Energetics session.

I Agree / Disagree to the above:*

I Agree
I Disagree

Date

Session Agreement Form

Session Agreement

COVID-19