Daphne Fay, SoulShine SpiritWorks LLC
Address: 2501 Chatham Road, Suite N

Springfield, Illinois 62704
Email: Daphne@SoulShineSpiritWorks.com

1. Purpose and Nature of Services

I understand that I am receiving services in emotional healing and/or energy balancing from Daphne Fay, a practitioner of alternative and complementary health care. These services are intended to support my general wellness and do not replace medical diagnosis or treatment provided by licensed healthcare professionals.

I understand that:

• Daphne Fay is not a licensed physician, psychologist, or other licensed health care provider.
• The services provided are not licensed by the State of Illinois, but are offered under the Illinois Alternative Health Care Freedom of Access Act (225 ILCS 64).
• The practitioner does not diagnose, treat, or cure any disease, illness, or condition in the conventional medical sense.
• Emotional healing, energy balancing, and energy healing modalities are complementary modalities and are not substitutes for medical care.

2. My Responsibilities as a Client

I understand that:

• It is my responsibility to consult with a licensed medical provider for any physical or mental health concerns.
• I will inform [Your Name] of any current medical conditions or medications that may be relevant to the services provided.
• I am fully responsible for my health and well-being and for all decisions I make regarding the use of alternative or complementary health practices.

3. Confidentiality

All personal information shared with Daphne Fay will be kept strictly confidential and will not be released without my written consent, except as required by law.

4. Voluntary Participation and Results

I understand that:

• Participation in these services is completely voluntary.
• No guarantees have been made regarding the outcomes of any sessions.
• I may stop participation at any time.

5. Emergency Care

I understand that Daphne Fay is not equipped to handle medical emergencies, and in the event of an emergency, I will contact 911 or visit the nearest emergency facility.

Client Acknowledgment

By signing below, I acknowledge that I have read and understood this consent form. I consent to receive emotional healing and energy balancing services from Daphne Fay.  I understand the nature of the services, the limits of practice, and my responsibilities as a client.