Informed Consent & Agreement

 Informed Consent and Agreement

Practitioner representations:             

Character of practice and licensure:  I am a certified practitioner of Emotional Freedom Techniques (EFT) in the experimental field commonly known as “energy medicine” or “energy psychology.” These words are to be construed in their most general and broadest possible use.  There is no licensure available for EFT.  I am an “unlicensed EFT Practitioner/Coach.  (Examples of other unlicensed practitioners include life coaches, business consultants and performance specialists such as those specializing in athletic or artistic performance.)  My coaching style is to operate on a peer-to-peer basis facilitating clients’ learning to achieve their own self-identified goals and to assist clients in enhancing their ability and skill in self-applying the stress-reduction technique of EFT, for which instruction and training are readily available at no cost on the internet. EFT has produced remarkable clinical results, but there is no guarantee that it will be successful in all cases.

Qualifications:   I hold an original certification from EFT’s developer Gary Craig and have EFT certified through EFT Universe. Over the previous 25 years I’ve completed studies and coached in areas including, but not limited to, counseling, client-centered hypnotherapy, and Neuro Linguistic Programming.

Limits of my practice:   As I am neither a medical doctor nor a mental health professional, I specifically do not offer or provide diagnosis or treatment of medical conditions or of mental disorders (as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders.)  Clients are urged to seek professional medical or mental healthcare whenever appropriate.  EFT Coaching is not a replacement for medical or mental healthcare from licensed professionals.

Client representations:

I acknowledge delivery of the statements above.  I have been informed about the field of practice that works with one of more aspects of the human energy system to bring about body-mind relief.  I have been informed about scientific studies that confirm the value of these approaches for releasing trauma and anxiety and increasing relaxation and reducing pain sensation which can be found in detail on the research pages at EFT Universe:  http://www.eftuniverse.com/index.php?option=com_content&view=article&id=18&Itemid=21  and The Association for Comprehensive Energy Psychology:  http://energypsych.org/displaycommon.cfm?an=1&subarticlenbr=290. I have been advised that there are currently no known negative side effects when energy-oriented methods are administered by a qualified practitioner.  I understand that these methods are relatively new and considered experimental, that the extent and breadth of their effectiveness, including benefits and risks, are not yet fully known.  I have been advised of the following:

Reactions may surface during a session that neither my Practitioner nor I can fully anticipate, which may include strong emotional or physical sensation. After the session, memories of additional emotional material may continue to surface and give indication of other incidents that may need to be addressed. My practitioner may refer me to other practitioners who have specific skills to help in area beyond his/her scope of practice. Light touch may be involved in assessment with clinical kinesiology (also known as muscle testing) for which I can choose to give permission or not.  My practitioner may use selected touch to facilitate a session but will ask for my permission before using touch. I will be learning personal self-care using my own energy system as part of the process.  

Professional Fees, Billing and Payment:    I understand that the fee for a 90 minute session is $125.00.    If we decide to meet for a longer session, I may, at the Coach’s discretion, be billed at this hourly rate.  I agree to pay for each session at the time it is held unless we agree otherwise in advance.  Once an appointment is scheduled, I agree to pay for it unless I provide 24 hours’ advance notice of cancellation and to do so prior to the next session.  If I arrive late, the Practitioner will have the option of ending at the scheduled time so as to not run into time previously otherwise scheduled.  In addition to scheduled appointment, I agree to pay for any other professional services which I may request at the same hourly rate such as emergency telephone conversations lasting longer than 10 minutes, reading and responding to emails other than for routine business, the attendance of my Practitioner at meetings with other professionals which I authorize, including preparing requested records or summaries, etc.  If I become involved in legal proceedings that required the Practitioner’s participation, I and agree to pay for the Practitioner’s time if the Practitioner is called to testify by another party.  I understand that because of the difficulty of legal involvement, I will be charged and agree to pay $125.00. per hour for preparation and attendance at any legal proceedings, including postponements. I will make payments either in cash or by check to EFT Clarity Works LLC., which I acknowledge is the business entity through which the Practitioner operates.  For my convenience, arrangements may be made to make payments to EFT Clarity Works LLC using a credit card via the PayPal account at .

Confidentiality:   I understand that I am entitled to confidentiality with certain exceptions in which reporting may be legally required, such as current abuse of a minor, elderly, or disabled person, or the threat of serious bodily harm to myself or others.  Confidentiality may no longer be legally protected should a judge make certain orders in certain legal proceedings and I have been advised to consult with an attorney if I am involved in a legal situation in which such confidentialities may be at issue.

 

Legal Proceedings:   If I am involved in legal proceedings based on my having been traumatized, my goals and/or this work may involve resolution of the physical and emotional aftermath of the trauma, and successfully reaching those goals of resolution could adversely affect my ability to provide legal testimony that carries the same impact as it would prior to this coaching.

As a condition of entering into this Consent to be served (on my part) and Agreement to serve (on the practitioners part) I warrant that the information and that the history (which may be continued below) and any information provided in our intake interview is accurate to the best of my knowledge as will be any information provided in follow-up interviews.  The Practitioner may rely upon this information in determining whether to accept or maintain me as a client.  I agree to take responsibility for keeping the Practitioner updated on my physical and mental condition.

Other Aspects of Our Relationship:    I have the right to, am encouraged to, and agree to ask any questions I may have about anything that happens in our work together and to make suggestions as to what might work better. I understand that the Practitioner is willing to discuss the Practitioner’s decisions and to look at alternatives. I can ask about the Practitioner’s training for working with my concerns and can request that the Practitioner refer me to someone else if I decide the Practitioner is not the right Practitioner for me.  I am free to terminate our work together at any time.  If I am anything other comfortable talking to the Practitioner, I have been encouraged to talk through such concerns with another professional.  

My signature below indicates that I have read, understood and agreed to this document and that after having fully discussed any questions or matters of concern with the practitioner and/or others, I agree to abide by its terms during our professional relationship.  I choose to engage in the innovative approaches of energy medicine on my own, free will.  My consent to the terms of this document are free from pressure or influence from any person or group,  I am not on a mission of entrapment or investigation and  I make all statements on my own behalf and not as an agent for another or person or entity.  I have considered the above information before agreeing to participate in energy related coaching sessions and have obtained whatever additional information or professional advice I consider necessary to make an informed decision.  I have the right to cease using these methods at any time.  I agree to take full responsibility for my own emotional, physical, and mental safety and well-being both during any coaching sessions and in working with EFT personally. 

I understand that the EFT Coaching given here is for the purpose of stress reduction, gentle energy circulation, and coaching toward my goals.  I further understand the EFT Practitioner is not a licensed physician or mental health professional and does not diagnose or treat illness, disease or any other physical disorder or prescribe medical treatment or medication(s).  I have been specifically informed specifically acknowledge that EFT Coaching is not a substitute for professional medical or physical or mental healthcare and have been advised to see those whenever appropriate.  

  ____________________________________________  Date

Signature of Client

 ____________________________________________  Date

Signature of Parent or Guardian if under 18

 ____________________________________________   Date

Marilyn McWilliams,  Practitioner/Coach as the member of EFT Clarity Works LLC.

503-281-0195     email: 

Website:  www.EFTCatalyst.com