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Rio de Ki - Somatic Naturotherapy
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10 Session Bioenergetic Session Agreement
Package – 10 Session Bioenergetic
About You
Your Name
(Required)
First
Last
Preferred nickname, if any
Preferred pronouns
(Required)
She/her
They/them
He/him
Other
Your Email Address
(Required)
Your Phone
(Required)
Do you want an insurance receipt?
(Required)
Yes
No
Verify with your provider that they cover Naturotherapists covered with the ACNN (Academy of Naturopaths and Naturotherapists of Canada).
Your Address (If you require an insurance receipt)
Street Address
City
ZIP Code
Service Agreement
(Required)
Holistic Naturotherapy Sessions: The package includes ten 90-minute holistic naturotherapy sessions with Rio, which include integration assignments between sessions.
In-Between Session Support: Support between sessions is available via email or WhatsApp. Rio will respond within 48 hours, up to two times per week.
I agree to the scope of service
Payment Policy
(Required)
Ten 90-minute holistic naturotherapy sessions with Rio, with integration assignments in between
For a fee of $1500, payable in 3 x instalments of $500 at the beginning of session 1, session 4 and session 7.
Insurance receipts will be given following each session, and will equal the total amount paid divided by 10.
I agree to the payment policy
Cancellation Policy
(Required)
Please note the following regarding cancellations:
1. Therapy Room Reservation Fee: A non-refundable $30 fee is required to reserve the therapy room. If you cancel within 72 hours of your appointment, this fee will be deducted from your session package deposit.
2. No-Shows: No-shows will be charged the full session fee. Late cancellations or missed appointments prevent us from offering that time to other patients.
To avoid these charges, we recommend confirming your appointments no more than one week in advance.
I agree to the cancellation policy
Somatic Naturotherapy Consent
(Required)
I consent
By checking this box, I am consenting to Naturotherapy and Bioenergetic sessions and the experience of Somatic Release. I acknowledge that some stored emotion and emotional trauma may be brought to the surface as a part of the transformational process. this work is deeply experiential and may involve spiritual, emotional and physical release.
I knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my session with Rio de Ki.
Somatic Naturotherapy Consent
(Required)
I consent
I understand that somatic healing sessions may involve touch and physical contact, which will always be respectful, consensual, and client-driven. I hereby provide clear written consent for touch as part of our sessions. I understand that I have the right to withdraw my consent at any time.
I understand that the practitioner will respect my boundaries, and I am encouraged to communicate any discomfort or request adjustments at any time during the session.
I acknowledge that the practitioner is not a licensed medical professional and does not provide medical or psychological diagnosis or treatment.
By signing this form, I confirm that I have read and understood the above information, and I am providing my informed consent for somatic healing sessions. I am also aware that I have the right to review and discuss any aspect of this form with the practitioner before starting the sessions.
Signature
(Required)
By signing this form I consent to a Naturotherapy session using Somatic and Bioenergetic modalities. I recognize that at times I release Rio from all responsibility from whatever may come up for me emotionally during or following the session.
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