PO Box 475 Southern Pines, NC 28388 USA
Phone: 1.910.692.5206 USA Fax: 1.910.692.5103 USA
Atlanta, GA Office: 1.404.242.9022 USA
Email:
Brent@BrentAtwater.com
page 1 of 3
B BRENT ATWATER:
CLIENT INFORMATION
(One of three pages) DATE : Atlanta, GA
office: 1.404.242.9022 NC Office: 1.910.692.5206 USA Email: Brent@BrentAtwater.com
NAME:____________________________________________________________________ (last name
first) first middle
nickname
BIRTHDATE:________________TIME:_____________PLACE:____________________
OCCUPATION:________________________________ PHOTO:___________
HOME
ADDRESS:_______________________________________________________________
_________________________________________________________________
CITY: _______________________STATE:___________ PSTL
CD:_________COUNTRY:__________
HOME PHONE:______________________ EMAIL HOME: _______________________
HOME PHONE 2:_____________________ CELL PHONE:_____________________
OFFICE PHONE:_____________________ EMAIL OFFICE:_______________________
Referred by:____________________________________________TU_________________
Initial
Consultation and/or Energy work fee is: $ _________ USD RF$:__________
PD:___________
Alternative contact:_______________________________________________
Phone:_________________________________________________________
What do you want
healed? Initial inquiry & Medical information: (why called) see other
form for Medical specifics
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________
___________________________________________________________________________
Medical or Alternative
treatments or providers:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Medicines or Herbs:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
PO Box 475
Southern Pines, NC 28388 USA
NC Phone: 1.910.692.5206 USA NC Fax: 1.910.692.5103 USA
Atlanta, GA Phone: 1.404.242.9022 USA
Email: Brent@BrentAtwater.com
I,
_________________________________________________(Please print),
(the "Client")
understand that B Brent Atwater, of Energy Work, Inc., is a healer, medical
intuitive, and intuitive
consultant and does not present herself as a medical doctor nor as
possessing any specific or formal medical training, nor as a licensed,
registered or certified practitioner or counselor. I seek Ms. Atwater's
Consultation
and Energy work to improve my health and life through her intuitive
evaluation, consultation, and the
Energy that she channels.
I acknowledge that I understand the following:
1. I seek Ms. Atwater's Consultation and Energy work freely and of my own
accord without coercion or duress and with full knowledge of the limitations
of the services that she offers. I take full responsibility
for seeking appropriate mental, emotional, and health care for myself. If I
have any symptoms, adverse reactions, or illness, it is my responsibility to
seek the care of a trained medical practitioner of my choice.
If I am consenting to the intuitive evaluation, consultation, or energy work
as the legal guardian and caretaker for someone else, I am also advised to
consult with a trained medical practitioner and my legal advisor before
participating in any of Ms Atwater's intuitive suggestions
2. Ms. Atwater has
advised me to disregard, throw out, and don't participate in, or use any
intuitive information or suggestions that Ms. Atwater suggests that do not
resonate with my personal choices,
my intuition, or my soul and to consult with a trained medical
practitioner and my legal advisor before participating in any of her
intuitive suggestions. Ms. Atwater's intention in providing intuitive
information
is purely informational and not for medicinal or curative purposes and I
take it as such. Her intuitive recommendations are not intended to prevent,
diagnose, mitigate, or cure any illness or disease, or any emotional and or
mental problems or personal problems.
3. No one representing Energy Work, Inc., or Ms. Atwater offer me any false
hope or false expectations, promises, warranties, assurances of the success
or the outcome of any of Ms. Atwater's recommendations
or Energy work. I agree to hold Ms. Atwater, Energy Work, Inc. and it's
representatives free and harmless from any liability, demands, claims, suits
for damages for any injury or complications whatever, save negligence, that
may result from such recommendations and or Energy work and from any adverse
reaction
I may have to the Energy work, or to any intuitive recommendation.
4. I understand my
initial Consultation and/or Energy work fee of
$_________ USD is non
refundable.
a. I understand that my non-refundable
deposit of $ ________ USD will be used to secure my appointment.
A 24-hour notice is required if I must cancel or rearrange any
Follow-up Consultations or Energy work sessions, otherwise my Consultation
or Energy work fee shall be charged to me, or my debit or credit card.
b. I understand that if
time permits, and I choose to extend my counseling session beyond the stated
timeframe for my original Consultation, that I am responsible for paying for
that additional time. All additional time shall be billed at the rate of $
55.00 USD per 15 minute increments. These additional charges shall
be paid for by me, or charged to my credit or debit card at the end of that
specific session.
5. I understand that one Full Day Rate fee plus any non
refundable travel expenses for my Consultation and Energy work are non
refundable should my consultation have to be canceled. I
understand that my obligation for Ms. Atwater's expenses are: to provide
hotel accommodations chosen by Ms Atwater, a round trip flight from wherever
Ms. Atwater currently is, and her ground transportation. I also understand
that I must make payment for Ms Atwater's trip in USD in advance.
I understand and agree that Ms Atwater will work with us for a minimum of
___ days.
I understand and agree that my travel Consultation fees are as follows:
Day Rates:
Minimum charge:
$ USD
Half Day Rate (4 hrs work) is: $_________USD,
Full Day Rate (8 hrs work) is: $ _________ USD,
I understand and agree that my travel
Consultation Total Advance Day Rates are: $
Travel expenses:
Round Trip Flight:
Hotel:
Ground Transportation:
I understand and agree that my travel
Consultation Total Advance Expenses are: $
I understand and agree to pay my travel
Consultation Advance Payment of: $
I
understand that my non-refundable deposit of $ .00 USD
will be used to secure my appointment.
I also understand and agree to pay any out of pocket
documented expenditures for the above named travel expenses incurred by Ms
Atwater that were not covered in the advance payment. I understand and agree
that these expenditures will be charged to my credit card or I will pay Ms
Atwater for these expenditures within 10 business days of her submission of
her receipts and documentation upon her return.
B Brent
Atwater: CONSULTATION CONTRACT
(Three of three pages)
for onsite, remote, or distance energy work, onsite consultations, and or
telephone consultations.
5. I fully understand that the healing Energy may facilitate my
actual physical healing or the Energy
may accelerate my crossing over as a form of my "healing". I understand
that only GOD determines
how the Energy
will affect and effect my physical body and my life, and that there are no
guarantees.
I am of sound mind, and not under any mind altering drugs. By signing this
agreement, I acknowledge
that I have read the above, have thoroughly reviewed and understand its
contents, and that I am giving
my informed consent and agree to it. By my written acceptance of this
agreement, I know this document becomes a legally binding contract.
SIGNATURE OF CLIENT OR PERSON LEGALLY AUTHORIZED TO CONSENT FOR THE
CLIENT, OR PERSON CONTRACTING MS
ATWATER'S SERVICES
Date:
____________, 2004
Signature:_________________________________________________Seal
Witness to
signature:___________________________________ Date:
_______________
Please print the
following for the Signor:
Name: __________________________________________
Phone:_______________________
Address: _________________________________________________________
_________________________________________________________
__________________________________________________________
Relationship to
Client:__________________________________________________________
If using a debit or credit card, Please
provide the following information about your card:
Type of card:___________________
Your name as it appears on the
card:_______________________________________________
Card number :______________________________
Expiration date of your card:___________
The last three numbers on your signature strip:_____________
The Billing Name and Address as it appears on your credit card statements:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________