EFT Waiver

Date

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Best Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact

Emergency Contact Phone #

Please enter a valid phone number.Format: (000) 000-0000.

Liability

I hereby release Jeanne Steen from any liability or claims that could be made against her concerning my mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form.

Scope of Practice

I understand that Jeanne Steen is not a licensed physician, psychologist, or medical practitioner of any kind and that EFT Tapping should not be considered a replacement for the advice and/or services, of a psychiatrist, psychologist, psychotherapist, or doctor.

It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have.

I understand that EFT Tapping can complement any medical or psychological care I may be receiving. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

By signing this document, I agree to assume and accept full responsibility for any and all risks that may be associated with EFT Tapping.

I acknowledge that I will be reviewing memories with emotional content and physical correlations and that I may continue to feel emotions after our session.

Guarantee

I understand that although EFT Tapping has an incredibly high success rates, Jeanne Steen cannot and does not guarantee results since my own personal success depends on many factors that Jeanne Steen has no control over, including my willingness and desire to affect the changes inside of myself and to particpate fully in any home care practice (i.e. practicing tapping).

Confidentiality

By signing this form, I consent that Jeanne Steen may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.

I also understand that, at any time, Jeanne Steen may discuss aspects of my case with other colleagues, or share it in her marketing to help others understand that transformation is possible, keeping my full name and identity completely confidential always unless I have given permission otherwise.

Signature