1120 Alpine Ave., Suite E, Boulder, CO 80304, Phone: (303) 564-1210

 

Cacao Ceremony

DISCLOSURE STATEMENT, INFORMED CONSENT, AND WAIVER OF LIABILITY

The Cacao Ceremony will be guided by Helen Knight, a Reiki Master and Spiritual Alchemist. Ms. Knight began her training as a Shamanic practitioner in 2012, completing Lower World Journey, Power Animals, and Helping Spirits with Gwilda Wiyaka at Path Home Shamanic Arts School in Colorado. Ms. Knight became a Reiki Master and Teacher in 2013 after studying Usui Reiki in the Australian Outback. She studied healing, clairvoyance, and spiritual topics at Psychic Horizons Center in Colorado for 2.5 years. In 2014, she completed her third year of a four-year Vision Quest in Colombia. She also studied Bach Flower Remedies in Santiago, Chile. For the past three years, she has been teaching Reiki workshops. She has been working as a Reiki practitioner/healer for over 8 years. Ms. Knight is a member of the International Association of Reiki Professionals.

During this Cacao Ceremony, Ms. Knight will guide you on a shamanic journey. You will be offered a cacao beverage made simply from organic cacao and hot water. We will start with a guided meditation, and then you will be invited to lie down. You will be asked to think of an intention or question on which you would like to receive guidance or healing. With the sound of the drum, you will slowly enter a deep meditative state where you will enter an interactive dream, led by your guides, angels and power animals. During this journey, you will be guided to open your heart to new awareness and healing. Towards the end of the ceremony, Ms. Knight will give each person 1-2 minutes of Reiki, which is a hands-on healing practice during which Ms. Knight will move her hands lightly on or over your body. The entire session will last about three hours.

As a Complementary and Alternative Health Care Practitioner, Ms. Knight is not licensed, certified or registered by the state of Colorado as a health care professional. Ms. Knight is not a licensed physician or surgeon, and she does not diagnose, treat or prescribe remedies for the treatment of disease. The services she performs are at all times restricted to complementary and alternative health care services. She does not perform surgery or any invasive procedure, administer or prescribe x-ray radiation, administer or prescribe prescription drugs, dispense or suggest any controlled substance, use general or spinal anesthetics, administer ionizing radioactive substances, use a laser device that incises the skin, perform enemas or colonic irrigation, 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, recommend the discontinuation of a course of care or a prescription drug that was recommended by a health care professional, or treat children under eight years of age. In order to treat a child between 2 and 8 years of age, additional consent forms must be completed and signed by the child’s parent or legal guardian. Ms. Knight carries liability insurance applicable to injuries caused by an act or omission of Ms. Knight 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.

 

Please answer the following questions:

  1. Are you taking any anti-depressant, anti-anxiety, or anti-psychotic drugs that contain SSRI?
  2. Are you highly sensitive to caffeine?
  3. Do you have any heart problems or heart conditions?
  4. Are you allergic to cacao or chocolate?

Please check each box below to confirm the following:

 I agree not to consume the cacao beverage if I am allergic to any cacao or chocolate products.

 I understand that if I am taking any medication for depression, anxiety or psychosis or if I have any heart conditions, I may experience an adverse reaction to cacao and therefore I should limit my consumption of the cacao beverage.

 I acknowledge that the cacao beverage and Ms. Knight’s statements have not been evaluated by the FDA and are not intended to diagnose, treat, cure or prevent any disease.

 I understand that Reiki is a gentle, hands-on energy technique that is used for relaxation and stress reduction and that it is not intended to diagnose, treat, cure or prevent any disease.

 I acknowledge that I should discuss with a physician my consumption of the cacao beverage and that I should immediately contact a physician if I suspect that I have a medical problem or reaction

 I acknowledge that I should discuss any recommendations made by Ms. Knight with my primary care physician, obstetrician, gynecologist, oncologist, cardiologist, pediatrician, or other board-certified physician.

 I understand that my participation in the Cacao Ceremony is not to be construed as a substitute for medical examination, diagnosis or treatment. It is recommended that I see a licensed health care professional for any physical or psychological ailment I may have.

 I recognize that I am free to decline to act upon Ms. Knight’s recommendations as I see fit and that I do not have to participate in any part of the ceremony. I acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with participation in any part of the Cacao Ceremony. I acknowledge that I am physically fit and mentally capable of performing the activity I choose to participate in.

 I agree to assume all risk of personal injury or loss, bodily injury (including death), damage to or loss of, or destruction of any personal property resulting from or arising out of participation in the Cacao Ceremony. I also release, waive, indemnify, hold harmless, and discharge Dreamtime Healing and Ms. Knight from all claims, damages, and injuries arising out of my participation in the Cacao Ceremony, including my consumption of the cacao beverage.

 I understand that I have received or will receive a copy of this Statement at the email address or mailing address provided below.

 I hereby certify that I am over 18 years of age and that I have read, understood, and accepted all the statements in this document.

 If the participant is 12 to 18 years of age, the participant’s parent or guardian hereby accepts the above terms on behalf of minor participant and grants permission for the minor’s participation. The parent or guardian also agrees to attend the Cacao Ceremony with the minor and certifies that the minor is 12 to 18 years old. Minors under 12 years old are not permitted to participate in the Cacao Ceremony.

Name of Participant

Signature of Adult Participant or Minor’s Parent/Guardian

Name of Parent or Guardian (if Participant is a Minor)

Date

Email address of person signing

Residential address of person signing