New Client Questionnaire - Living Voice Medicine

Welcome! Please fill out and submit the form below before scheduling your appointment. You may want to copy and save any long responses in case something happens to the form. Feel free to be as detailed or concise as you want. Fields with asterisks are required. In filling out the form you will be sent an e-mail invitation to sign up for my (infrequent) newsletter, which you can use to accept or ignore the invitation.

First Name *

Last Name *

Email Address *

Phone Number *

What pronouns should be used to refer to you?

she/herhe/himthey/themother - will explain in-session

What types of sessions are you interested in? *Ancestral Lineage HealingSpirit HealingMentoring/Intuitive Feedback

What is your current intention for sessions? *

What forms of healing work have you engaged in the past and what forms are you currently engaged in? *

For Spirit Healing Sessions, please indicate which of these, if any, you have experienced within the past year. Persistent anxiety and/or depressionPersistent negative thoughtsPersistent thoughts of suicide and/or deathThe death of someone close to youA sense that something essential is missing in your life.Loss of consciousness due to surgery, accidents, or out of body experiences.Abuse or trauma that has had a lasting impactSpirit disturbances or recurring disturbing dreamsWill discuss in session

For Spirit Healing Sessions, please indicate which of these, if any, you have experienced historically. Chronic anxiety and/or depressionPersistent negative thoughtsPersistent thoughts of suicide and/or deathThe death of someone close to youA sense that something essential is missing in your life.Loss of consciousness due to surgery, accidents, or out of body experiences. Abuse or trauma that has had a long-term impact on your life. Spirit disturbances or recurring disturbing dreamsWill discuss in session

For Ancestral Healing, what regions of the world are your ancestors from (if known)?

If you have already started Ancestral Lineage Healing, where are you at in the process? (e.g. I have completed two primary lineages and have been working on the third.)

Anything else you would like me to know?

Mental Health Policy *Maris is not trained in mental health assessment or trauma support, and does not hold that particular kind of therapeutic space. This work is not recommended for people with unstable mental health conditions, those who are in crisis, or those who are experiencing substantial active trauma. Kindness to those who are, but other forms of healing work with practitioners who work directly with those conditions is recommended instead. If you are not in crisis, are in stable mental health, and not experiencing substantial active trauma please verify by checking this box.

Appointment Policy *Please check this box indicating you have read and agree to this Appointment Policy: In particular that 48 hour notice is required for cancellations and rescheduling, no refunds will be made for no-shows or late cancellations, and appointment duration will not be extended for late starts unless the lateness is on my end. Please contact me by e-mail if you will be late or are having technical difficulties. Payment for session is due 48 hours in advance and serves as confirmation for your appointment.

Type your name in the box below to sign the Treatment Consent and Hold Harmless Agreement (text below) *

Treatment Consent and Hold Harmless Agreement

I, the electronic signer above, hereby authorize Maris Bergrune (legal name Melissa Rosenberger, hereafter referred to as Maris) to perform the following procedures and services as scheduled:

Spirit Healing: the use of subtle energy techniques including, but not limited to, journey work, energy extraction, cord-cutting, spirit release work (compassionate depossession), soul and essence retrieval, power retrieval, energy body reading and clearing, curse unraveling, sound healing, and mediated ancestral healing.

Ancestral Lineage Healing: facilitation of the ancestral lineage healing process developed by Daniel Foor. These sessions are facilitated and supported by the practitioner but not mediated by the practitioner. Clients are empowered to connect with and relate to their own well ancestors, and the well ancestors mediate the healing work for the lineage. Follow-up suggestions and guidance for engaging the process will be given.

Mentorship/Intuitive Feedback: discussing goals, life situations, behavior modifications, energetic techniques, and personal history and perspectives for the purpose of self-understanding, self-empowerment, and the improvement of the quality of life.

By scheduling a session with Maris you affirm that you have read the following statements indicating understanding and consent of the conditions presented:

I understand that Maris is not a therapist or medical provider, and that this work is not therapy or medical treatment, or a substitute for therapy or medical treatment. I understand that this work does not intend to diagnose, treat, or cure disease or mental illness. I understand that this work is not for people experiencing unstable mental health conditions, those who are in crisis, or those with substantive active trauma. I understand that this work is transformative/catalytic and that I am responsible for acquiring the mental health support, aftercare, or integration work needed to process this work, as recommended by Maris or according to my own self-assessment and judgment.

I will not hold Maris or The Golden Lyre LCC legally responsible for any physical, emotional, mental, circumstantial, or energetic effects that may occur in connection with my participation in sessions. I recognize and agree that I am fully responsible for my well-being during my session, which includes disclosing any concerns and/or questions I may have before, during, or following my session.

I understand that Maris does not guarantee any specific result from treatment courses, and that she is unable to predict or control what my outcome may be. In receiving treatment I am willing to assume the risk of this uncertainty.

I understand that during a course of treatment some symptoms or circumstances may be “activated” or exacerbated. I may experience new symptoms as layers of work come up for processing, and I may experience an exacerbation of existing symptoms as the work progresses. I understand that usually these states are temporary and resolve with a completion of the work, but that no guarantees can be given about their resolution.

With this knowledge, I voluntarily consent to the above procedures and services, realizing that no guarantees have been given to me by Maris regarding the cure or improvement of my conditions. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Maris and The Golden Lyre LCC and all its agents from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with the above mentioned procedures and services.

I understand that I am free to withdraw my consent and to discontinue participating in these procedures and services at any time. I understand that Maris may terminate our professional relationship for any reason, and in the event of termination will provide referrals for my continued care.

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