TRINITY LANE ELECTRONIC INFORMED CONSENT FOR ADULT:

Practitioner(s): Christina N. Lane, RN, KRM and/or Amy Hatch, CPNP, RM

Services: The services to be provided by the practitioner to the client may include any or all of the following: Reiki, Angel Messenger Card Readings, Tapping, Sound Sessions, Body Work, and other available holistic treatments not listed here, as determined jointly during sessions. All information shared is strictly confidential and the client is encouraged to ask questions at any time. The client acknowledges that treatments involve physical touch from the practitioner to the client only. The client is encouraged to express any feelings of physical or emotional discomfort or unease should they arise. The client acknowledges that sessions are not guaranteed to cure, treat or provide relief from any disease or symptom. The client releases the practitioner from liability in the unlikely event of any physical or emotional injury or distress that may occur.

Disclosure: Although a practitioner may hold a board certification or license in Nursing, it is important that the client is aware the practitioner will not be functioning in this role for the purpose of treatment sessions.  General guidance on health and well-being may be given. However, the client acknowledges the practitioner is not a licensed counselor, nutritionist or massage therapist. All concerns regarding medical or mental health conditions should be directed to the client’s regular health care practitioners.

Appointments: Out of mutual respect, a 24-hour cancellation notice is requested. If 24-hour notice is not given, the full cost of the session is still due. As unforeseen circumstances arise, exceptions may be made upon discretion of the practitioner. If you arrive late for your scheduled appointment, we will do our best to accommodate. However, in respect for all, we do not guarantee that you will receive your full treatment if you are late to your scheduled appointment.

Communications: Acceptable forms of communication include text, call, e-mail, or messaging through social media and/or trinitylane.us. Please allow up to 24 business hours for a response. Clients are encouraged to reach out again if no reply is received within that time frame.

Privacy: Any information shared between practitioner and client is strictly confidential.

I am aware that practitioners are mandated reporters in the commonwealth of Massachusetts and this confidentiality may be broken if the client is at risk of harming themselves or others. Any communication between practitioner and any third party requires expressed written consent of the client or parents/ guardian if the client is under 18.

Payment: Acceptable forms of payment include cash, Venmo or credit card.. I am unable to accept health insurance or flexible spending account funds. Payments are expected at the time of visit.

Sound: While sound bowls (using Himalayan or crystal singing bowls) is generally a safe, non-invasive, and deeply relaxing practice, the intense acoustic vibrations and frequencies can affect the body. By signing below, you acknowledge and accept the potential risks outlined:

·        Vibrational and Implants Sensitivity: The physical vibrations produced by sound bowls can be intense. If you have recent injuries, fractures, joint replacements, or medical implants (such as pacemakers, metal plates, or screws), these vibrations may cause discomfort or interfere with devices.

·        Auditory Conditions: Sound baths can reach high volumes and sustained frequencies. If you suffer from severe tinnitus, hyperacusis, or other acute hearing conditions, the sound may temporarily intensify your symptoms.

·        Neurological Triggers: In rare instances, specific sound frequencies or prolonged acoustic stimulation can trigger episodes in individuals with sound-sensitive epilepsy or severe neurological conditions.

·        Pregnancy: If you are in your first trimester of pregnancy, it is recommended to avoid close-proximity vibrational therapy (such as placing bowls directly on or near the body), as the effects of deep resonance on early fetal development are not fully researched.

·        Mental and Emotional Release: Deep meditative states induced by sound therapy can occasionally trigger unexpected emotional responses, lightheadedness, or mild disorientation immediately following the session.

By participating in the Trinity Lane sound sessions, I confirm that I am in appropriate physical and mental health to do so. I understand that sound therapy is a complementary wellness practice and is not a substitute for professional medical diagnosis, advice, or treatment. I will notify the practitioners for any of the above conditions prior to participating in any sound session. I assume full responsibility for any risks, known or unknown, which I might incur as a result of participating.

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation.  I understand that Reiki practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed provider or licensed healthcare professional for any physical or psychological ailment I may have. I understand that any wellness discussions and/or recommendations that arise during a reiki session must be reviewed and consented to by a licensed physician prior to initiating any change in my health and wellness. I understand that Reiki can only complement any medical or psychological care I may be receiving, but does not take the place of traditional medical or psychological care. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. I have read this statement of policy and understand its contents. I have asked any questions I may have about these policies and voluntarily consent to holistic sessions with Christina Lane, RN, KRM and/or Amy Hatch, CPNP, RM under the terms described above and acknowledge that I have the right to terminate this agreement should I no longer wish to receive holistic treatments from Christina Lane, RN, KRM and/or Amy Hatch CPNP,RM. I acknowledge that I have been offered a copy of HIPAA (Notice of Privacy Practices for Protected Health Information). (Please see copy of HIPAA below)

Practitioners:

Christina Lane, RN, KRM

Amy Hatch, CPNP, RM

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION:

No information about any client will be discussed with any third party without written consent of the client or parent/guardian if the client is under 18, unless required to do so by law. Any information from a Reiki session between practitioner and client may be kept as physical and/or electronic records to facilitate treatment of stress reduction and/or relaxation for each client. All personal information will be kept strictly confidential to the best of the practitioner’s ability.

rev. 7/4/2026