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KPI client intake/application form

Date
Month
Day
Year

Free study terms

  • Participant provides a short interview on video at the office, for public viewing and KPI promotion, without remuneration, when a noteworthy improvement occurs. Last names will not be used on website or video.

  • No-shows will not be offered a second chance to participate.


Client terms

  • My questions were answered to my satisfaction regarding ANSSR therapy and its various protocols. I hereby grant permission to Andrew Arneson, LMT to engage in somatic modalities legally classified as “bodywork” or "massage system." I hereby release Kohala Pain Institute LLC and associates from all claims and liabilities arising from the use of such modalities, indemnifying and holding the above harmless from all liabilities and claims therefrom, whatsoever.

  • ANSSR therapy facilitates comfort and relaxation. Physiologic self-regulation can be extensive. All results are spontaneous effects of relaxation, dictated by individual needs. ANSSR therapy is not intended to diagnose, treat, cure, mitigate, or prevent any specific disease.

  • ANSSR therapy is completely safe, non-invasive, and relaxation-oriented. Arneson is not responsible for any adverse conditions or adverse changes in my physical or emotional health.

  • I take full responsibility for my safety on the office property, outdoors and indoors.

  • Arneson is not a physician and makes no attempt to undermine the advice of my physicians.

  • I am free to discontinue these applications at any time.

  • ANSSR therapy requires total comfort for both client and practitioner. In the unlikely event that a client's conduct is incompatible with the method, Arneson reserves the right to refuse or discontinue treatment at any time, with or without a fee/refund at his discretion.


Cancellation policy

  • When scheduling, a credit card is required to hold the appointment, for no-show protection.

  • The full fee of $300 will be charged for no-shows or missed appointments.

  • Online scheduling changes or cancellations must be made no less than 48 hours before the appointment.

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