Intake Form

First Name

Last Name

Email Address

Address

City

State

Zip Code

City

Phone Number

Occupation

Date of Birth

Referred By

City

What are your goals for Higher Brain Living®?

Do you feel you have a purpose in life? What brings you meaning? What does your ideal life look like?

What activities, treatments, or other modalities do you utilize to improve your health or personal growth?

Higher Brain Living® Informed Consent And Notice of Informed Consent

I hereby request and consent to receiving Higher Brain Living® (HBL) sessions. HBL is a revolutionary discipline based on an organic shifting of energy from lower brain dominance to Higher Brain living in 45-minute sessions. Once the Higher Brain becomes energized, information and energy added into the system in the right place, at the right level, and in the right time allows an evolving nervous system rapid reorganization and growth both in the internal (mind) and external (physiology) of an individual, thereby promoting emergent properties in body, mind and spirit.



During TIER 2 and 3 the client will use their newly energized Higher Brain to make positive changes in any or all areas of their life. ReSOULutions are created and utilized relative to the information gathered through the Evolution in 4 dimension process available through HBL. The associating of key words/phrases, thoughts and visualization into the physiology needed to produce the positive change occurs in TIER 2 and 3 and is unique to the HBL process.



Although many methods for healing and personal growth may use varied breathing techniques, body motion, emotional “release,” or self-touch to produce an altered experience, none that we know of have the implicit goal of engaging the Higher Brain. Practice members in care commonly remark that HBL is the most powerful growth and transformational service that they have ever experienced.



That said, HBL is an empowering self-help and self-advancement tool that provides a map and a guide and, except as may be provided in your purchase agreement, we cannot and do not guarantee the success of any HBL practice member. You are ultimately responsible for reaping the quantum benefits of this unique new discipline.



Your HBL facilitator will not diagnose, treat, or offer advice on any specific disease or symptom. HBL is not a substitute for medical care nor it a psychological intervention, and HBL in no way enters into those arenas. If you want medical advice, or counseling, please seek the appropriate professional.



HBL is designed to help you energize your Higher Brain and discover new wellness, growth and lifestyle possibilities.



During the course of care, practice members commonly feel their self-awareness heighten when experiencing HBL sessions. You may experience intensity both during sessions in the office and afterward. Emotions may shift/increase/decrease. Since you will be learning to pay attention to your body’s subtle cues, areas that were “disconnected” from your awareness will awaken. You may experience physical sensations such as energy, vibration, heat, or at times discomfort (brief). The goal is that, in time, you will learn to redirect your body-mind’s attention from a distressing circumstance of the moment to inner safety, peace and power and to change your thought patterns, reaction patterns and habits that limit your growth.

PRACTICE MEMBER’S AGREEMENT

I have read the above Notice of Informed Consent and request to participate in the HBL program and HBL sessions. I understand that I will not be allowed to participate in any HBL sessions until I have read and signed this consent form. I further understand that I have been given the opportunity to review or have this form reviewed for me.



I additionally certify that I am at least eighteen (18) years of age, and I consent to allow the HBL facilitator to touch me for the purpose of assisting me in connecting to my Higher Brain . I understand that I may terminate any HBL session at any time. I further consent to allow the HBL practitioners to freely exchange information about my personal and clinical history among team members to create the most productive approaches to my care. I agree to allow such communication on an ongoing basis so that skills I am learning can be fine-tuned to compliment my circumstance, current life goals, and current TIER of HBL.



I further agree that my questions have been answered satisfactorily. The purpose of this consent form is to help me better understand the nature of the services offered in this center and our mutual responsibilities. This fosters a more effective relationship and avoids misunderstandings about the nature of HBL services being offered. I agree that should I have any further questions or concerns regarding any of the above or any aspect of the sessions or HBL, I will communicate them, as needed and on an ongoing basis, to my HBL facilitator or another member of the HBL staff.



This consent form is freely and voluntarily executed and shall be binding upon my spouse, successors, heirs, assigns, legal representatives, and administrators. I hereby release the HBL facilitators assisting me and Higher Brain Living, LLC, AWAKEN Higher Brain Living LLC and all officers, owners and shareholders from any and all liabilities associated with my HBL sessions.

I Agree To These Terms