I understand and agree that

• There is a new group of therapeutic approaches, including TAT, which work with the human energy system and are understood to affect the body/mind interconnection.
• Clinical experience and scientific studies are confirming that these approaches can assist in addressing conditions such as anxiety, phobias, and traumatic responses as well as enhancing relaxation, increasing a sense of well-being, and reducing pain sensation.
  
• There are currently no known side effects to energy-oriented sessions when properly administered by an experienced practitioner.
  
• No medical diagnosis, prognosis, or treatment is expressed or implied by TAT sessions facilitated by Jeanine DuBois. TAT is not a substitute for medical treatment.
  

• Other emotional and physical sensations or additional unresolved memories may surface.
• Previously vivid or traumatic memories may fade. This could adversely impact the ability to provide detailed legal testimony regarding a traumatic incident.

• Anything addressed or revealed is received by Jeanine with respect and will be held in honored confidence.

• So that she can be of maximum support to me, I will communicate to Jeanine:
• my comfort preferences (temperature, lighting, water, restroom, blankets) as well as physical or emotional sensations,  which seem important, surprising, uncomfortable, or delightful
• any pertinent insights, observations, or requests - any guidance I sense about what might be helpful

By signing below, I acknowledge

• all statements above
• my choice to utilize TAT of my own free will
• my right to cease using this approach at any time
• I agree to take full responsibility for my self-care in the physical, emotional, mental, and spiritual dimensions of my life.

Session Participant: X____________________________________________________ Date____________________

Name (printed)_________________________________________________________________________________

Address_______________________________________________________________________________________

City___________________________________________________ State____________ Zip code _______________

Country________________________________________________ Phone__________________________________

Email_________________________________________________________________________________________


May I send you email updates about upcoming workshops or special rates?       Yes        No