Form Distance Energy Consultation – Human

Please right-click this link to download the form as a fillable PDF.  You may fill it out on your device and email it to Marci at the email address shown on the form.

Alternatively, you may fill out the online version, below. Upon submission, you’ll see a message within a green box that says, “thank you, your message has been sent”, directly beneath the “submit” button. If you don’t see it, please scroll down.

    Clarity Consults LLC
    PO Box 841 • Pleasant Hill, OR 97455
    Phone: 541.915.5715 • Fax 541.343.7700

    codyclarityconsults@gmail.com

    Consultation Form for Human  
    Client Information:

    I consent to all distance energy treatments.

    -Agreement for Services-

    1. Financial Agreement

    I require payment at the time of service.
    My Phone Consultation fee is $160.00 for the first session, $150.00 for follow-up sessions.
    Initial Session: $160

  • Includes reviewing New Client email covering issues and goals, initial 10 minute phone consultation to answer
    questions and review issues/goals, the session itself, and a follow-up 10 minute phone call or email.*

    • Follow-up Sessions: $150

  • Includes email contact to set up date & time and discuss problem area(s), the session itself, and a follow-up
    email. *

    • Emergency sessions are available, schedule permitting:

  • Initial Session $175, Follow-up Session $150

    • *Further phone consultation time is available at a rate of $25 per 10 minutes, billed in 10 minute increments, $25
    minimum

    1. Financial Agreement

    In consideration of receiving service rendered by Marci Cody, I hereby declare

  • My true and legal name is as signed below and not otherwise.

  • I understand and have been informed that Marci Cody may be able to assist in my feeling better AND that
    there is no scientific proof to show that it works.

  • I have been informed that Marci Cody is not a medical doctor, and I am aware that she is not licensed
    under laws of this state to practice medicine.

  • I understand that Marci Cody’s sessions are not physical therapy and are not a substitute for physical therapy treatment.

  • Marci Cody has stated she will neither diagnose nor prescribe for any medical condition or problem from
    which I may appear to be suffering. She has suggested, should I have any physical or mental complaints, I
    should consult a licensed medical practitioner.

  • I have been informed and I understand that Marci Cody makes no guarantees or promises that I will
    improve.

  • I am 21 years of age or older.

    • Please prove you're a human by answering this Math Captcha 🙂 − 3 = 1