I, First Name* Last Name*, understand that Milana Leshinsky is not a licensed therapist, psychologist or health care practitioner and offers EFT (emotional freedom techniques) as a life and business coach.
I am aware that Milana Leshinsky 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 Milana Leshinsky without consulting my doctor. (Please initial) Initials*
I understand that EFT is considered a “complementary” or “alternative” procedure and is not a substitute for medical, psychological or psychiatric treatment or medications, and that it is recommended that I currently work with my primary caregiver for any condition I may have. (Please initial) Initials*
I understand that EFT procedure 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. (Please initial) Initials*
I also understand that previously traumatic memories may lose their emotional charge and this could adversely affect my ability to provide convincing legal testimony. (Please initial) Initials*
I understand that all information I share with Milana Leshinsky is confidential and that no information will be released to any third party without my express written consent, with the following exceptions:When there is imminent risk of danger to myself or another personWhen there is suspicion that a child, elder or disabled person is being sexually or physically abused or is at risk of such abuseWhen a valid court order is issued for session records (Please initial) Initials*
I give Milana Leshinsky permission to record my session for certification purposes only. (OPTIONAL: Please initial) Initials
I agree to take complete responsibility for my own comfort, health and well-being while working with Milana Leshinsky. I agree that typing in my name below is the electronic equivalent of my actual signature. (Please initial) Initials*