Disclosure Form

Anne-Marie Wiesman

 Disclosure Statement and Client Informed Consent

Services-

Thank you for your interest in working with me as a client for EFT Tapping, Hypnosis or Reiki.

Our work together will include a shared understanding of what you hope to accomplish and agreements for supporting those outcomes. Although I will share my skills and abilities to support your growth and personal development, my work with you is only a resource. As an intentional and conscious participant in your growth, you will ultimately take all responsibility for and actions related to furthering your life journey.

As part of my practice, I offer a type of energy therapy identified as Emotional Freedom Technique (“EFT” “Tapping”) . EFT Tapping appears to have promising mental, spiritual, and physical health benefits but has yet to be fully researched by the Western academic, medical, and psychological communities. EFT is a relatively new healing approach and the extent of its effectiveness, as well as its risks and benefits, are not fully known. The prevailing premise is that EFT uses the ancient Chinese meridian system to relieve emotional stress and physiological pain and it balances the energy system with a gentle tapping procedure which stimulates designated meridian end points on the face and body.

By signing this document you understand that EFT Tapping could be considered experimental. If you ever have questions or concerns about the nature of the theories and methods I use, including EFT Tapping, please feel free to ask me for further resources or references.

As a practitioner of EFT Tapping, I will provide you with the services described in the attached Description of Services which is incorporated herein by reference and made part of this Disclosure Statement and Informed Consent. Any methods I use, including EFT Tapping, are considered alternative or complementary to healing arts.I am not a psychotherapist, a registered or licensed counselor, a licensed physician nor are my services licensed by the State.

 

Please be advised that in our work together emotional or physical sensations or additional unresolved memories may surface which could be perceived as negative side effects. It is possible to experience some emotional distress and physical sensations related to prior life experiences. The clinical reports from energy therapies such as EFT Tapping show no additional side-effects when used appropriately. Emotions may continue to arise after a session and you are encouraged to discuss such emotions with me. In addition, previously vivid or traumatic memories may fade. This could adversely impact your ability to provide detailed legal testimony regarding a traumatic incident.

You agree to take full responsibility for your self-care in the, emotional, mental, physical, and spiritual dimensions of your life.

Please be advised that EFT Tapping, Hypnosis and Reiki are not used to diagnose, treat, cure, or prevent any disease or psychological/mental health disorder. Consequently, EFT Tapping sessions do not provide medical diagnoses nor do they offer cures; they do not replace health care from medical professionals.

You agree to consult with your health care provider for any specific medical problems. If you ever have any concerns about the nature of your sessions, please feel free to discuss them with me.

Education and Training

I have been using EFT since early 2002.

My training in EFT includes the following:

  • EFT Practitioner Training with Ingrid Dinter  2011
  • EFT Cert 2- Certification through AAMET 2012
  • 2012-Hypnotherapist Training and certification 2012
  • Ordained Interfaith Minister with the Universal Life Church

Acknowledgment and Consent to Receive Services

By signing this document, you agree that I have disclosed to you sufficient information to enable you to decide to undergo or forgo EFT and/or any other energy based treatment methods and other services I offer. You understand that you are freely choosing to take advantage of my EFT Tapping, Hypnosis or Reiki services and would otherwise have the option of using conventional psychotherapy methods exclusively, provided by a therapist of your choosing. Your consent to this course of treatment is given voluntarily, without coercion, and may be withdrawn.

You represent that you’re competent and able to understand the nature and consequences of the proposed EFT Tapping, Hypnosis or Reiki sessions or procedures. You have read and understand the above disclosure about the EFT Tapping, Hypnosis or Reiki services offered by me and my training and education. You have discussed with me the nature of the services to be provided and you understand that I am not a licensed physician or psychologist and that my services are not licensed by the State. You understand it is your responsibility to maintain a relationship for yourself with a medical doctor. You have consented to use the services offered by me and agree to be personally responsible for the fees related to the services provided to me. By signing in the space provided below, you knowingly, voluntarily, and intelligently assume these risks and agree to release, indemnify, hold harmless and defend Anne Marie Wiesman, and her agents, consultants, and employees from and against any and all claims which you, or your representatives, may have for any loss, damage, or injury arising out of or in connection with your services.

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