Consent Form
Name
First Name
Last Name
Email
example@example.com
I am aware that Pamela Wright does not diagnose illness or disease, and does not prescribe medications. I agree not to discontinue or change any medications I am taking while working with Pamela Wright without consulting my doctor.
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(Please initial)
I understand that EFT and Matrix Reimprinting are considered experimental procedures and are not a substitute for medical, psychological or psychiatric treatment or medications, and that it is recommended that I currentlywork with my primary caregiver for any condition I may have.
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(Please initial)
I understand that EFT and Matrix Reimprinting procedures may bring unresolved and distressing memories and related emotions and physical sensations into my awareness, and it is possible that disturbing material may continue to surface after a session and require further work.
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(Please initial)
I also understand that previously traumatic memories may lose their emotional charge and this could adversely affect my ability to provide convincing legal testimony.
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(Please initial)
I understand that all information I share with Pamela Wright is confidential and that no information will be released to any third party without my express written consent, with the following exceptions: 1. When there is imminent risk of danger to myself or another person. 2. When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse. 3. When a valid court order is issued for session records
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(Please initial)
I give Pamela Wright permission to describe the details of my sessions to her students, colleagues and mentors for training or supervision purposes only, as long as my personal anonymity is strictly protected.
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(Please initial)
I agree to take complete responsibility for my own comfort, health and well-being while working with Pamela Wright. I agree that typing in my name below is the electronic equivalent of my actual signature.
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(Please initial)
Client signature (typing your name=consent)
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