Process Request Form Process Request Form Please fill out this form if you would like to request a Process. If you prefer, you may call us instead and request the process over the phone. This form must be read, completed and submitted by a person who is at least 18 years old. If the person who will be receiving the process is under age 18, this form must be completed and submitted by their parent or legal guardian. Today's Date* MM DD YYYY Name* First Last Phone*Email* For whom are you arranging the process?*If you are arranging the process for someone other than yourself, please enter the name of the person next to "Other."MyselfRelationship to the person for whom I am arranging the process.*For myself, type N/A.How old is the person who will be processed?*18 or OlderUnder 18Please select the type of facilitator you would like.*If there is a specific facilitator you would like to request, please enter their name next to "Other."Clinic Student ($25)Intermediate Facilitator ($50)Advanced Facilitator ($75)Not sure - I need more information (please enter your questions at the bottom of this form)Are you interested in an in-person process or a phone process?*In-PersonOver the PhoneEitherNot SureLocation*Please tell us the general location (your city, state or the nearest major city and country) where you would like to conduct your Process. We have the highest concentration of facilitators in the Utah Valley area, but we also have a number of facilitators sprinkled around the U.S. If we don't have a facilitator in your area, your process can be conducted over the phone.How did you hear about us?*Mailer couponStudent referralAgnes & DoraWord of mouthOnline/IHA websiteFacebookOther (Please indicate in the Additional Information box below)Additional InformationPlease use this space to share any information you would like us to have, to ask any questions, or share any comments/concerns.Client Consent I understand that nothing said, done, performed, typed, printed or produced by the Institute of Healing Arts, its officers, representatives, employees, students, graduates or associates is intended or meant to diagnose, prescribe, treat a disease or take the place of diagnoses by a licensed physician, psychologist or psychiatrist. I understand that the trainings, processing sessions, classes and techniques of the Institute of Healing Arts are intended only to promote healthy lifestyles and cultivate the mind/body connection. I understand that in an emotional processing session, a variety of non-invasive methods, modalities and programs may be used, including, but not limited to, bio-kinesiology (muscle response testing), guided imagery, NLP (neuro-linguistic programming), speaking out feelings, role playing, inner child work, chakra work, and visualization. I understand that it is the purpose of the facilitator in using these techniques to bring the client to a place of inner healing, and to create a strong sense of well-being and closure with the issues being addressed. I understand that the role of the Institute of Healing Arts is to provide a place and structure for facilitators to process clients. I also understand that facilitators are responsible for adhering to the professional ethics and values established by the Institute of Healing Arts. This form is a release form granting permission for a facilitator to process my family member, a person for whom I am the legal guardian, or myself, using the FOUR-STEP process. This authorization is valid only for the person named on this form, for any and all sessions of processing with any Institute of Healing Arts facilitator. I hereby assume full responsibility for arranging the emotional processing session(s) for the person named on this form, and release and discharge both the Institute of Healing Arts and the Emotional Processing Facilitator(s) from any and all claims, liabilities, damages, actions, or causes of action arising from the services received hereunder. By clicking the button below you indicate your acceptance of the Client Agreement above.