Disclosure Statement Form for Complementary and Alternative Health Practitioner Colorado

DISCLOSURE STATEMENT AS REQUIRED UNDER SB-215 FOR

COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS IN COLORADO

1.            Name:  Lisa Guyman

2.            Office Address:  Presently Distant Reiki Sessions only

3.            Office Phone:   (720) 683-0444

As a Complementary and Alternative Health Care Practitioner, I am not licensed, certified or registered by the state of Colorado as a health care professional.  I am not a licensed medical physician and do not diagnose, treat or prescribe remedies for the treatment of disease.  The services I perform, whether in person, by mail or by phone, are at all times restricted to complementary and alternative health care services intended for the maintenance of the best possible state of nutritional health.  I am prohibited from performing surgery or any invasive procedure, administer or prescribe x-ray radiation, prescribe prescription drugs, use general or spinal anesthetics, administer ionizing radioactive substances, use a laser device that punctures the skin, perform enemas/colonics unless board certified, practice midwifery, practice psychotherapy, perform spinal manipulation, practice optometry, directly administer medical protocols to a pregnant woman or a person who has cancer, practice dentistry, set fractures, practice massage therapy, provide a conventional medical disease diagnosis or recommend the discontinuation of a course of care recommended by a health care professional.  I am also prohibited from treating children less than two years of age.  In order to treat a child who is between 2-8 years of age, I must have a written, signed consent of the child’s parent or legal guardian:

The services I provide are as follows:  Reiki Treatments, Reiki Classes, Primordial Sound Meditation Classes.

My professional degrees, training, experience, credentials and qualifications are as follows:

Reiki:  I took a Reiki I, Reiki II, Reiki Masters and Reiki Teacher’s courses with Marnie Vincolisi.  I have been practicing Reiki since July of 1997 and I began teaching Reiki in 1998 just a few months after I took the Reiki Teacher’s course.  I’m registered with the International Association of Reiki Professionals (IARPReiki.org).  I am the author of “Journey Through Reiki” 5 CD set.  I’ve taught several hundred Reiki students to date and conducted Reiki treatments on hundreds of clients.

Meditation:  I am certified by The Chopra Center as a Primordial Sound Meditation instructor.  I took my training at The Chopra Center in 2004. I have produced two guided meditation CDs – one solo and one in partnership.  I first learned to meditate at the age of 16.  I have taught a couple hundred students in meditation.

Yoga Nidra:  I am certified by Samadhi Yoga Center as a Yoga Nidra Instructor.  I completed this training in 2014 under Jeremy Wolf.

I carry liability insurance applicable to any injury caused by an act or omission in providing complementary and alternative health care services.  A copy of this disclosure statement will be kept on file for at least two years after the last date of service.

*As my client, you should discuss any recommendations I provide with your Primary Care Physician, Obstetrician, Gynecologist, Oncologist, Cardiologist, Pediatrician or Pediatric Health Care Provider, or other Board-Certified Physician.

Name of Client                                                                                                  Signature of Client

Address of Client                                                                                             City, State, Zip Code

Phone Number                                                                                                 E-Mail Address

Date of Birth                                                                                                      Date of First Visit