RELEASE/CONSENT FORM

1.  I, Lavynya Carmen Croitoru, am not a medical physician or surgeon nor do I practice in that model, therefore I do not prescribe legend drugs or make recommendations about them, but will make referrals when requested or when I feel there is a need for that model.

2.  You, the client, are not to discontinue any medical treatment or medication without supervision and consultation from your treating physician.

3.  You, the client, are accepting services under good faith and free will, and following the dictates of your own conscience, which allows you to select what you understand is most beneficial to your health, and are accepting these services without guarantees. 

4. You, the client, understand that the biofeedback procedures utilized include stress reduction protocols, relaxation techniques, and pain management. The lawfully registered SCIO biofeedback device is intended for the purposes of relaxation, reducing stress, and muscle re-education and is legal to be used for those purposes. I, Lavynya Carmen Croitoru, warrant that all biofeedback equipment to be used during any biofeedback sessions with clients will be lawfully registered with the appropriate governmental agencies as required by law.

5.  This work is both alternative to and at the same time complementary to the biomedical model of Western medicine licensed by the state.  The holistic/wholistic approach involves the assumption that when one thing changes you change as a whole person.  

6.  There are no licensing bodies or requirements in this state for the Reconnective Healing®, Soul Body Fusion®, Touch for Health®, Brain Gym®, and Biofeedback models of health enhancement and therefore this service is not licensed by the State.

7.  Reconnective Healing®, Soul Body Fusion®, Touch for Health®, Brain Gym®, and Biofeedback are models of natural enhancement that have as their basis energy.  Reconnective Healing®, Soul Body Fusion®, Touch for Health®, Brain Gym®, and Biofeedback are about bringing people back to a natural state of balance, wholeness, and vitality.  This system is available to all people and professions, is not dangerous to use, and does not require a license by the state. However, healthcare providers licensed to diagnose, treat, cure or prevent any disease or disorder may use biofeedback devices for any purpose permitted by their license.

8.  I, Lavynya Carmen Croitoru, am a Certified Biofeedback Specialist (CBS), Reconnective Healing® Foundational Practitioner, Reconnection-Certified Practitioner, a Brain Gym® Consultant, have my Touch for Health® Proficiency, and am a Soul Body Fusion® and Biofeedback® Practitioner.  I successfully completed the Certified Biofeedback Specialist program, as well as both the Reconnective Healing® Foundational Practitioner Program and the Reconnection-Certified Practitioner Program.  I have also successfully completed the programs to become a Brain Gym® Consultant and Touch for Health® Proficient.  Again, I am not a medical physician or surgeon nor do I practice in that model.

**Your signature below indicates that you have read and understood the information in this document and that you consent to training under the provisions stated. If you do not understand or consent to anything stated in this document, it is your responsibility to request and receive clarification before signing.

By entering your name below, you agree to the conditions listed above.

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