Client Informed Consent

Empowered Living, LLC Informed Consent

Ali Jacobs, 62 Cedar Drive, Durango, CO 81301, 970-903-3189

Please understand, that I, Alexandra Jacobs, am a facilitator, coach and Licensed Massage Therapist (which I will refer to as a facilitator, practitioner or as Empowered Living, LLC throughout the remaining of this disclaimer) and am practicing under the protection of the Colorado Natural Health Consumer Protection Act. The practice of massage therapy is also regulated by DORA – Colorado Department of Regulatory Agencies.

I, ________________________ understand that I am the decision maker for my health care. Part of Empowered Living, LLC’s role is to provide me with information to assist me in making informed choices. This process involves my understanding and agreement regarding the care that is being recommended, the benefits and risks associated with the care, alternatives, and the potential effect on my health if I choose not to receive the care. This disclosure is for you to know the professional boundaries and scope of work provided through Empowered Living, LLC and to make an informed decision.

As of June 2013, the state of Colorado has enacted the Colorado Natural Health Consumer Protection Act (SB 13-215) to provide an exemption from state regulation for unlicensed complementary and alternative health care services. The law makes it clear that in Colorado a person who is practicing complementary and alternative health care services consistent with the requirements of the new law will not be unfairly prosecuted for not having a license to practice medicine as long as they do not engage in an activity listed on the prohibited list, such as performing surgery, puncture of the skin, prescribing legend drugs or controlled substances, or fail to fulfill the disclosure duties in the law.

Therefore, in the state of Colorado, I recognize that Alexandra Jacobs is a complementary and alternative health care practitioner. I acknowledge that the alternative therapies offered through Empowered Living, LLC, includes, but is not limited to, consciousness facilitation (Access Consciousness® & Psych-K® Facilitation), reiki, embodiment coaching, therapeutic massage therapy, ancient cupping and hot stone therapy and other integrative modalities, such as homeopathic and herbal medicines, which all falls under the guidelines of this act.

I acknowledge I am being offered treatment to help bring my body mind back into balance in a holistic manner affecting my physical, emotional, and spiritual health. Empowered Living, LLC is not liable or responsible for the results of any actions taken (or not taken) as a direct or indirect result of any of the services provided to me. Furthermore, I acknowledge that those who are assisting me with my wellness goals at Empowered Living, LLC have explained the healing services available to me and have made their credentials known to me.

Alexandra Jacobs graduated from Ithaca College, Ithaca NY in May 2005 with a Bachelor of Science degree. Graduated from the Rocky Mountain Institute of Healing Arts, Inc. in Durango, CO in June 2006 with a Diploma in Therapeutic Massage which consisted of 825 hours of massage therapy education. Completed 200 hours of “Be the Love” Yoga Teacher Training in Petosky, MI in 2014. Completed Psych-K Basic and Master Facilitation Training in Aurora, CO in 2022 which consisted of 28 hours of instruction and 20 hours of practicum. Alexandra Jacobs is a registered and licensed Massage Therapist in Colorado (MT.0019892), regulated by the Colorado Division of Professions and Occupations.

I understand that a Licensed Massage Therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I understand that massage therapy or cupping should not be performed under certain medical conditions. I affirm that I have informed Empowered Living, LLC of any known medical conditions and answered all questions to the best of my knowledge and ability during the intake process. I agree to keep the practitioner informed of any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

Alternative therapies, used in the scope of practice at Empowered Living, LLC also do not diagnose, prevent, cure, or treat any mental disorders, medical disease and are not intended to be used as a substitute for counseling, psychotherapy, mental health care, substance abuse treatment or other professional advice by legal, medical or other qualified professionals. Alternative therapies can help you develop tools for emotional growth & physical healing but does not take the place of therapy or other necessary treatment.

While I do not expect Empowered Living, LLC to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the practitioner to exercise educated judgment during the course of treatment and to make intentional suggestions that are with my best interest in consideration. I understand that results are not guaranteed and there is no promise to cure.

I understand that in the event that my condition is such that treatment is beyond the normal capabilities of the practitioner, that I may be referred to other competent practitioners. I also understand I may seek a second opinion from another healthcare practitioner at any point or may terminate treatment at any time, no questions asked.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for any payment for the scheduled appointment.

I understand the staff of Empowered Living, LLC may review my patient records, but all of my records will be kept confidential and will not be released without my consent, unless permitted by law.

You are agreeing that you have read, understood and agree to the items contained in this document.

-Ali Jacobs, Empowered Living Creator