I hereby state that, to the best of my knowledge, my answers to the questions are correct. I agree that I am receiving treatment of my own free will. I agree to not take legal action against Serenity Space LLC, or its constituents, should I experience any negative results from the treatment or sessions.

I agree and consent to assessment and treatment. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

I agree to express myself if I find myself uncomfortable or experience any pain or discomfort during the session.

I understand that this is a professional setting and inappropriate behavior, including but not limited to sexual advancements or harassment, will NOT be tolerated. Any such behavior is will result in session termination, and if necessary, police notification.