Client Information EFT

Date

Name

First NameLast Name

If under 18 years of age Name of Parent/Guardian

Telephone

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

Name Phone

Have you been in therapy or had psychiatric treatment in the past?

YesNoIf Yes DescribeOther

Are you currently under psychiatric care or in psychotherapy?

YesNo

Are you currently on any medication(s) for your physical or mental health?

If Yes Describe

If yes, please list name of Health Care Practitioner

Please describe your spiritual beliefs. Which statement(s) best describe you? I believe in God or a Universal Spirit

I'd prefer to not answerI believe in God or a Universal SpiritI do not believe in God or a Universal SpiritI am not sure if there is a GodI am not religious but I am spiritualI am both religious and spiritual

Comments on Faith or Belief

Optional

Please describe what you would like to gain from our work together

Is there anything else you would like for me to know?

Whom may I thank for your visit?

Kenneth Rodriguez 3204 Sw 100th St. Gainesville FL. 32608

I understand that Kenneth Rodriguez is an Accredited Certified Emotional Freedom Techniques (EFT), Thought Field Therapy (TFT) practitioner/trainer and Ordained Minister, Pastoral Life Coach, Life Purpose Life Coach. His EFT Certifications are through Complementary Therapists Accredited Association (CTAA) His ministerial ordination is with Open Ministry. His EFT,TFT Life Purpose Coach Certifications are through Complementary Therapists Accredited Association (CTAA). He is not a psychotherapist, psychologist, physician or other government licensed health care professional. As a Pastoral Life Coach he provides spiritually focused education, and applies principles and techniques for enhancing spiritual and personal growth/healing, inner guidance and inner peace including working with the body’s energy meridians. I understand that EFT/TFT work is physiological yet can be spiritual in nature, and of intangible spiritual benefit, and thereby possibly also benefit the mind, emotions, and body and enhance personal and/or professional aspects of life. I understand that Emotional Freedom Techniques (EFT),Thought Field Therapy (TFT) is a technique based on the ancient Chinese energy meridian system. It involves tapping on specific meridian points with the fingers while at the same time thinking about what is bothersome. Evidence is growing that the body’s electrical and subtle energies are involved in the experience of unwanted emotions and that stimulating the meridian points causes the energy disruption responsible for the negative emotion to be released.

A critical review of 50 peer-reviewed clinical outcome reports and systematic studies of EFT and TFT published in an APA journal, Review of General Psychology, states: "A literature search identified 50 peer-reviewed papers that report or investigate clinical outcomes following the tapping of acupuncture points to address psychological issues. The 17 randomized controlled trials in this sample were critically evaluated for design quality, leading to the conclusion that they consistently demonstrated strong effect sizes and other positive statistical results that far exceed chance after relatively few treatment sessions. Criteria for evidence-based treatments proposed by Division 12 of the American Psychological Association were also applied and found to be met for a number of conditions, including PTSD." (Feinstein, 2012)

At this time there is only limited published research in established scientific journals investigating the use of EFT and related energy techniques. I understand that these reports do not constitute conclusive scientific evidence regarding effectiveness, and that even if the effectiveness becomes scientifically established results will vary from person to person. I understand no guarantee or prediction can be made regarding the results of using EFT/TFT. I understand that reactions may surface during sessions that are not anticipated, including strong emotional or physical sensations. I further understand that it is possible that unresolved memories and related emotions may be brought into my awareness through the use of EFT/TFT, and that emotional material may continue to surface after a session and give indication of other concerns that may need to be addressed. I also understand that the memories may lose their emotional charge and/or may change in some way that could adversely affect my ability to provide legal testimony the same way I would prior to the EFT/TFT session(s) I understand that EFT/TFT is not used to diagnose, treat, cure, or prevent any disease or psychological/mental health disorders. Consequently, EFT/TFT sessions do not provide medical diagnoses, nor do they offer cures. I understand that EFT/TFT is not meant to replace standard medical care and/or mental health counseling. I agree to consult with my health care provider(s) regarding the appropriateness of my use of EFT/TFT before participating in EFT/TFT sessions. I understand that it is recommended that I see a physician or other licensed health care professional for any physical or psychological ailment I may have. I understand that Kenneth Rodriguez does not recommend that I stop using any prescribed medicine or other kind of therapy that I may be using without consulting the appropriate licensed health care provider.

I understand that client sessions are confidential except under certain circumstances. These include when the client is possibly at risk of being a threat or danger to self or others; and, when there is a reasonable suspicion of abuse or harmful neglect of child, dependent or elderly person. I agree to take full responsibility for my well being, should I decide to learn EFT and explore its benefits as part of my work with Kenneth Rodriguez. I bear the responsibility for any decision I make based on my work with him. I further agree that Kenneth Rodriguez shall not be liable to anyone for any loss or injury resulting from the direct or indirect use of any services or information that he provides. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Kenneth Rodriguez from and against any an all claims of liability of whatsoever kind or nature arising out of or in connection with my session(s) In addition, if I choose to do EFT/TFT sessions via phone, the internet or any electronic platform I understand it isn’t possible to guarantee confidentiality and I agree that Kenneth Rodriguez will not be held liable for any breach of confidentiality over those technologies or forms of communication.

Initials

I have thoroughly considered all of the above and have obtained whatever additional input and/or professional advice I deemed necessary or appropriate about commencing sessions that utilize EFT. By my signature below, given freely and without pressure from any person, I consent to the use of EFT/TFT in my sessions. I understand that fees are $125 per hour. Sessions over one hour are charged on a prorated basis in 15-minute segments. I understand that payment is due at the time of my appointment, or prior to my appointment time if I am making my payment online, unless other arrangements have been made in advance. I understand that if I need to change my appointment time I am asked to give 48 hours notice. IF LESS THAN 24-HOUR NOTICE IS GIVEN I UNDERSTAND I WILL BE CHARGED THE FULL FEE FOR THE SESSION.

Print Name

Date

Signature

IF YOU ARE A PARENT OR GUARDIAN PLEASE COMPLETE THE INFORMATION BELOW

Child’s or Charge’s Printed Name

Kenneth Rodriguez 3204 Sw 100th St. Gainesville FL. 32608Efttele.com

Client Information EFT

Client Information EFT

Disclaimer and Informed Consent Form