Client Intake & Liability Form

Please fill out the following form in order to participate in Psyche-Body Sessions. 
By completing this form, you acknowledge that you understand Amanda Blain is not a licensed mental health care provider. She operates independently as a Yoga Alliance Registered teacher specializing in yogic psychology, therapeutic movement, and is educated in trauma-informed approaches through the National Institute for the Clinical Application of Behavioral Medicine. 

I certify that I have completed my initial consultation with Amanda Blain, RYT, and have agreed to receive private Psyche-Body sessions which would include guided self-inquiry, psyche training, meditation, and movement as a means to address the issues discussed on our call. 

I understand that Amanda Blain is not a licensed mental health professional, and that her expertise in the field comes from non-traditional education including private mentorships with body-centered psychotherapists, certifications in Primal Vinyasa® and Tantric Hatha yoga, and trauma education through the National Institute for the Clinical Application of Behavioral Medicine. 

I understand that it is my responsibility to seek the advise of a licensed mental health professional should I encounter concerns or complications with my mental health. 

I understand that Primal Vinyasa®, yoga, and Therapeutic Movement include physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I will continue to breathe smoothly. I assume full responsibility for any and all damages, which may incur through participation in Psyche-Body sessions with Amanda Blain. 

Psyche-Body sessions are not a substitute for medical attention, examination, diagnosis or treatment. By signing, I affirm that a licensed physician has verified my physical condition to participate in such a program. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my signature verifies that I have my physician's approval to participate. I also affirm that I alone am responsible to decide whether to participate in Psyche-Body sessions, and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Amanda Blain, Psyche Body Soul, and all businesses located at 10349 W. Fair Avenue Unit A, Littleton, CO 80127.

I have read and fully understand and agree to the above terms of this Client Intake & Liability Form. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law.

Thanks for submitting!