CONSENT FOR SERVICES & TOUCH-BASED MODALITIES
I voluntarily consent to receive services from Kelly Graver, a certified practitioner in the
modalities listed above. I understand:

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• These services are not a substitute for medical, psychological, or psychiatric treatment

• Kelly Graver does not diagnose, treat, or prescribe for any medical or mental health conditions

• Kelly Graver is acting solely within the scope of her certification in the state(s) of Arizona and California and is not practicing any profession that requires a medical or psychotherapy license

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For sessions that may include somatic breathwork or Bio-Touch, I understand there may be light
physical contact (e.g., chest, abdomen, sternum) to support relaxation or somatic processing. I
grant permission for such therapeutic touch, with the understanding that I may decline or
withdraw consent at any time.

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MENTAL HEALTH DISCLOSURE
If at any point it becomes evident that your needs exceed the scope of these services, I may
recommend you seek support from a licensed medical or psychiatric provider. Such
recommendations will be documented and discussed with you in full.

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SESSION EXPIRATION & PAYMENT TERMS
All prepaid sessions must be used within 180 days of purchase unless otherwise agreed upon in
writing. I agree to pay all fees in full and in a timely manner. If a payment plan is in place, I
agree to abide by its terms. If no such plan exists, all fees are due on or before the time of
service.

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ACKNOWLEDGEMENT & SIGNATURE
I have read and understand the contents of this Disclosure and Consent Form. I agree to the
terms as outlined above and have received a copy for my records.