AarchEchon

Do you do substance abuse, like smoking, drinking, and or any internationally classified drugs?

Yes
No

What is it you want to get help for? Tell us about your problem in your own words?

Are you aware of how it works?

What is your reason for choosing this discipline of natural therapies?

Do you suffer from any medically diagnosed illnesses/allergies, hereditary or otherwise? If yes please let us know?

Is there anything else you would like to make us aware of - medically or otherwise?

Please note that all the information written by the client or client's guardian will be considered as the factual truth and shall be dealt with confidentially. If and when needs be we shall discuss and share the given information with other practitioners.

Healing and Medicine are two very different disciplines. The information and healing techniques that we offer you is of holistic approach and is neither medicine nor a medicinal tool.
Therefore our services to you here are in any respect/aspect will not constitute or substitute Medical advice and assistance. In case of any serious illnesses you may have been suffering with, you must please consult the appropriate Medicinal Practitioner of your choice.

Declaration

(Please read it carefully, dont casualy scroll)

By submitting this request form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Aarchechon harmless for any unauthorized use, disclosure, or access of your protected health information shared via this electronic means.

I have been explained properly and I understand thoroughly the program that they offer. Am solely responsible in choosing this wellbeing program and will go through this program as per the instructions given by my Practitioner. In case if I don't I shall not hold anyone else accountable at all for the adverse consequences I may suffer.

I also understand that, this program is uniquely designed to fulfill my current needs and the above given information is adequate true and complete to the best of my knowledge .I knowing that my personal information is kept and dealt with highest confidentiality, shall permit my recordings to be used solely to undergo integrated analysis according to their internal procedures.

I understand that I should pay the total fees charged in advance for the therapy I undergo as directed by Practitioner. Unless there is an arrangement that has been agreed with the therapist.

In case of any changes in the scheduled plan from our side I understand that I should inform at least 24hrs before the session, failing to do so we may incur a fine of up to 50% of the scheduled session's cost.

I agree.

Your Signature

Personal Details

Introduction and Acquaintance

Address

Declaration

(Please read it carefully, dont casualy scroll)