This is a complimentary 25 minute session with Tiffany Cano on her Soul of An Empath Podcast.

First Name

Last Name

Address

City

State

Country

Postal code

Email *

Phone *

Are you coachable... and willing to do action steps or guidance that I suggest that could help you?

Are you open and receptive to coaching and healing?

What *SPECIFICALLY* do you want me to focus on during this session? Since this is a 25 minute session, I need you to be very specific. An example might be about an end result you want to achieve such as: "I want to live in my heart space," "I want to make more money," "I want to heal a relationship with _____," I want to learn to trust myself," "I want to heal an old wound about ____," "I want to hear my intuition," "I want better boundaries with _____," "I want to clear overwhelm/anxiety/depression etc," or "I want to feel more loved/seen/heard/understood in regards to ____."

Please list 3-5 specific items and then I'll intuit what will be best for this session. *

Please list any other diagnosis or diseases not listed from above:

Do you have a history of psychological disorders? If so, please list:

Do you take recreational drugs? If so, what kinds and how often?

Please list any past or upcoming surgeries that you have had (and approximate dates):

Please list any medications, vitamins or herbs that you are taking:

Please list any accidents:

HOMEWORK ASSIGNMENTS: I agree to complete assignments within the timeframe suggested to further my healing and manifestation of my goals and intentions. The assignments may include: tithing, acts of service, meditation, journaling, going for a walk, being in nature, etc. I understand the assignments are essential and I accept full responsibility for stepping outside of my comfort zone as needed to complete the assignments.

I have read and agree.

Disclosure Agreement * Disclosure in Compliance with New California State Law Bill Number SB 577: Act to add to Sections 2053.5 & 2053.6 of the Business and Professions Code, relating to health. “I understand that the Pranic Healing Practitioner from whom I seek services is not a licensed physician or surgeon and that Pranic Healing treatments are not licensed by the state but are complementary to healing arts services licensed by the state. I understand that Pranic Healing is a highly developed system of energy based healing techniques that utilizes “Prana” to balance, harmonize and transform, the body’s energy processes by cleansing, energizing and balancing the body’s bio-electromagnetic field, or aura.” *

I have read and agree.

It is my choice to receive Pranic Healing. I understand these modalities are not meant to replace conventional medicine. I realize the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, or for increasing circulation or energy flow. This also includes relief of phobias, addictions, or emotional trauma. I understand the practitioner does not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. If symptoms persist or become severe, a medical professional is to be consulted. I hereby release the person or persons providing these services from any liability of the services received. I certify that the facts given herein are correct and up-to-date and will notify the practitioner of any changes in my health status.

I have read and agree.

I understand this complimentary session will be posted on Tiffany Cano's Soul of An Empath Podcast. HIGHLY PERCEPTIVE PEOPLE ACADEMY LLC INTERVIEW CONSENT & RELEASE By proceeding to schedule or participate in an interview to be conducted by Highly Perceptive People Academy (hereinafter “Interviewer”), You Agree that you are over the age of 18, and Consent to the following Terms of Participation, including Release of Liability:

1. Permission to Record / Permission to Use. You, (the “Interviewee”), for good and valuable consideration which is hereby acknowledged, consent to participate in an Interview to be conducted by the Interviewer, and consent to the video, audio, and/or photographic recording and broadcast, including via live-streaming, of said interview. You hereby grant to the Interviewer and Interviewer’s assigns, licensees and successors the right to copy, reproduce, distribute, and otherwise use all or a portion of the video and/or audio recording in any format (the “Recording”) and your statements (the “Interview”) for incorporation in the Interviewer’s work (the “Work”) or for use by Interviewer for any commercial purpose without restriction. You also agree to the use of all or a portion of the Recording and the Interview in all forms and media, including live video and audio streams, audio, video and photographic recordings, transcriptions, including excerpts or segments, or edited or redacted versions of the same. You expressly grant Interviewer the right to capture and use your image, likeness, voice and name in connection with all uses of the Recording and Interview, and waive the right to inspect or approve use of the Recording or Interview as incorporated in the Work or otherwise utilized by Interviewer for any commercial purpose
2. Release. By agreeing to participate in the interview, you discharge and release Interviewer and Interviewer’s agents, representatives, assigns, licensees and successors from any and all claims that may arise regarding the use of the Interview including but not limited to any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity or copyright
3. Ownership. You acknowledge that you have no ownership rights in the Recording, the Interview, or the Work (though a copy or copies may be provided to you in the sole discretion of Interviewer, including for you to distribute or share as appropriate and only in accordance with any instructions or information provided by Interviewer and accompanying the Recording, Interview or the Work). You shall retain all original ownership rights in and to your original intellectual property including any copyrighted material utilized or referred to in the Interview
4. No Requirement to Use. Interviewer is not obligated to utilize the rights granted in this Agreement
5. No Joint Venture. You agree that no joint venture, partnership, employment or agency relationship exists between You and Interviewer as a result of the relationship established by this Agreement
6. Governing Law. This Agreement and any action related thereto shall be governed by the laws of the State of California without regard to its choice of law principles. The parties consent to exclusive jurisdiction and venue in federal and state courts sitting in Orange County, CA

I HAVE READ AND UNDERSTAND THIS INTERVIEW CONSENT AND RELEASE AGREEMENT, AND CONSENT TO THE TERMS HEREIN. * "I have read and consent to this agreement."

"I have read and consent to this agreement."

I agree to use a USB mic plugged into to my laptop/phone with a headset OR a plugged in headset for better sound quality.

USB Plug-in Mic + earbuds/headset (RECOMMENDED)

or a Plug-in Headset with microphone

And I'll be in a quiet room during the recording.

Thank you for being my podcast guest. :) The audio will be made available to you after it's edited. If you have any other questions, please let me know via text or email.

I will see you in my Zoom Room for the recording (I will only be using the audio and your first name in the recording). Please meet me at https://zoom.us/j/8237017129 for your scheduled appointment.

Thank you! I look forward to your session!

Blessings, Tiffany

Captcha