Our Inner Wisdom ~ Charli Lundholm
Disclosure and Consent Form

I want to share some information with you so you’ll have the knowledge you need to be comfortable in deciding to work with me. I realize it is a bit long. Please read it and sign the bottom. Let me know if you have any questions.

Healing modalities I use:

I utilize a foundation in traditional Usui Reiki, as well as intuitive guidance and energy healing. These are all forms of complementary health care practices, which have been found to aid the body in relaxing, restoring energetic balance and enhancing wellness. The body relies upon a flow of life force energy to maintain its health and wellness. Certain circumstances, such as illness, stress, or injury can restrict this flow. Emotions, beliefs and thought patterns can also constrict this vital energy. By balancing the energy pathways and thus restoring the flow energy, the body relaxes and calms, supporting its ability to heal itself.

Some people find one session to be helpful. More chronic imbalances may require multiple sessions to help the body restore its balance. I can’t give you a guarantee as to results, outcome, or length of time required, as no healer can. There are layers to healing, and you get to use your own intuition to decide how quickly you want the journey to go. To fully benefit from energy work, the client needs to be an active participant in their healing process.

How I work:

After we speak about what you are wanting to work on, I will start by getting a sense of your personal energetic state. Many times the energy around a person is chaotic or thick. Sometimes it is full of other peoples energy, making it difficult to see the true energy of the person I am working with. If this is the case, we will start by doing some clearing.

From there I will look at the energy throughout your body and see where there are blocks or constriction. I will channel guided information as to what the energetic cause may be, as well as how to clear it. Usually the body will let it be known what it wants, or needs, to heal.

This is not a one person show. Your participation is vital in discovering and releasing what needs to go. It is very empowering as well. You heal yourself. I am a facilitator, a conduit of the life force energy. The energy is guided by Source and used for your well-being on the physical, mental, emotional and spiritual levels.

About me:

I am a Reiki Master/Teacher, energy healer and an intuitive. I have been practicing and teaching Reiki and energy healing in my private practice since 1994. As a retired nurse, I have a good understanding of the physical body as well as Western medicines treatment plans. I am a strong believer that healing doesn’t have to come from one ideology, but can occur from the combination of Western and Eastern philosophies. I have also been in the crystal and mineral business for decades and am the owner of EarthGallery.com.

This work is complementary to health care, not a replacement or substitute.

I am not a licensed physician, and Reiki and energy healing does not require licensing by the state. It is a complementary treatment to traditional Western medicine provided by doctors and other licensed medical professionals and must not be considered a replacement or substitute for such proper care. I will not diagnose, or prescribe substances, nor claim to cure any medical or psychological problem and advise that you seek professional advice as appropriate before making any health decision. Any discussion of health conditions is incidental to healing of energetic imbalances and should not be misinterpreted as a form of diagnosis or treatment.

Payment for Services:

Any changes to current fee schedule will be discussed and payments will be expected at time of booking, or service. If you cancel or reschedule and don’t give 24 hour notice, the full price of the session will be charged.

Confidentiality:

Your experiences and information during our sessions are kept strictly confidential, unless you instruct me to release information to a specified health care practitioner. The only exceptions are if I am subpoenaed or otherwise legally obligated (including circumstances where there is clear and imminent danger to yourself or another person.)

Client Acknowledgement & Consent to Receive Services

In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will be provided with a digital or paper copy for signature. I will keep the original in my records for three (3) years.

~  I have read and understand the above guidelines and disclosure about the treatments and techniques offered by Charli Lundholm, as well as her training and education. I agree to ask any questions or voice my concerns about anything I do not understand.

• ~ No guarantees as to the results of treatment are expressed or implied by Charli.
• ~ I have discussed, or will discuss, with Charli any concerns I have about the nature of the treatment that she will be providing.
• ~ I agree to take full responsibility for my own health care.
• ~ If I experience any discomfort during the session(s), I agree to immediately inform Charli.
• ~ I understand that Charli is not a licensed physician and that the services that she will be providing to me are not licensed by the State of California.
• ~ I understand that Reiki and Energy Healing are not substitutes for medical treatment or medications. I am aware that Charli Lundholm does not diagnose illness or disease nor does she prescribe medications or other substances. I understand that any suggestions that are provided to me should not be taken as a diagnosis or recommendation against the advice of a licensed physician or mental health professional.
• ~ I have consented to use the services offered by Charli Lundholm, and I agree to be personally responsible for her fees in connection with the services provided.
• ~ Treatment is in accordance with California Senate Bill SB-577. If requested, I have been provided with a copy of California Senate Bill SB-577.

Client Acknowledgment:

By typing my full name and date in the Make Appointment Order Form, I am agreeing that I have read and understand the above disclosure regarding the Reiki and energy healing treatment(s) which I will be receiving from Charli Lundholm. I have been provided a copy of the above document by printing this page.

(Revised November 2021)