Private Session Agreement
Certified by Skills to Change Institute:
FasterEFT Advanced Level IV Practitioner, Certified Eutaptics Level 4 Practitioner
Certified by Transform Destiny, LLC:
Neuro-Linguistic Programming (NLP), Clinical Hypnotherapist (CHT), Success and Life Coaching,
Emotional Freedom Techniques (EFT), and Time Techniques (TT)
My mission is to teach personal transformation skills that give you increasing control of your thoughts and emotions, enable you to release stress, and create a positive effect in the quality of your life. By transforming what you think, and how you feel, your whole life can change!
Disclosure, Responsibility Statement & Client Agreement
(The “client” is the signer below)
1. I am at least 21 years of age, of sound mind, and am entering into this agreement of my own volition and by my own choice, and I am entering into this agreement for my own benefit and not on behalf of any other person.
2. I understand the term “mental healthcare provider” as used in this agreement refers to psychiatrists, psychologists, therapists, and any other professionals and facilities, which provide mental health services.
3. I understand and agree that Jean Erickson, or anyone else affiliated with Think. Feel. Change!, is/are not acting in the capacity of a doctor, licensed dietician, licensed nutritionist, psychologist or other licensed or registered professional. Accordingly, Jean Erickson is not providing health care, medical or nutrition therapy services and will not diagnose, treat, or cure in any manner whatsoever any disease, condition, or other physical or mental ailment of the human body.
4. I understand and agree that I should consult with a licensed physician or mental healthcare provider for any conditions I am suffering from prior to my attendance and participation in any program or services provided by Jean Erickson or Think. Feel. Change! Coaching and agree to their supervision if suggested. I further understand that I should continue consulting a licensed physician or licensed mental healthcare provider after attending a program or receiving services from Think. Feel. Change! Coaching, including the taking of any medications. I will continue to take all my medications as prescribed and remain under the care of my physician or therapist for any medical, emotional or mental condition for which I am currently being treated or believe I may need treatment. I understand and agree that it is my sole choice and responsibility to choose the appropriate healthcare providers for all of my healthcare needs, whether physical or mental, and that Think. Feel. Change! Coaching is not and does not represent that it is a substitute or replacement for such healthcare treatments that a patient would normally seek out.
5. I understand that there are no guarantees of outcomes or results being made by Jean Erickson or Think. Feel. Change! Coaching, with respect to the use, practice, or implementation of the techniques or skills used or taught by Jean Erickson or Think. Feel. Change! Coaching.
6. I accept complete responsibility for my emotional and/or physical well being before, during and after sessions or classes with Think. Feel. Change! Coaching. If I choose to share these techniques with others, I agree that Jean Erickson and Think. Feel. Change! Coaching shall in no way be responsible for such persons. I further agree to indemnify and hold harmless Jean Erickson and Think. Feel. Change! Coaching from any claims by third parties to whom I choose to share techniques I have learned.
7. I represent I am solely responsible for the outcomes of using any of the skills or techniques learned from Jean Erickson and Think. Feel. Change! Coaching and I will not use these techniques to try to solve a problem for which it is not appropriate.
8. I take full responsibility for what I do with these techniques, and will hold harmless Jean Erickson or anyone else associated with the techniques, from any claims made by myself, or anyone whom I seek to help. Subject to the other provisions of this agreement, I may use any of the techniques on behalf of others or myself.
9. I understand that the services provided by Jean Erickson are limited to education pertaining to my overall well-being. I understand these services may include a person physically tapping on my body at various acupressure meridian points, or instructing me to tap on the points myself. I grant my permission for limited physical contact to provide this service. I agree to inform the person performing the services immediately if it causes me any physical discomfort.
10. I understand that these techniques may reveal some problems I may have forgotten, but they don’t cause new problems. I understand that I can choose to accept or not accept any recommendations and that I may terminate our relationship at any time.
11. I understand that insurance may not cover services provided by Think. Feel. Change! Coaching and that I am fully responsible for payment in full of any services provided, whether or not the services are covered, in full, in part, or not at all by insurance.
12. No refunds after services have been rendered. No refunds or rescheduling for no-shows. If the client cuts short a session for any reason, that session is deemed completed. Rescheduling may be done with 48 hours prior notice, subject to available openings in the schedule. Partially used packages will not be refunded, but remaining sessions may be used by family members. Packages must be used within 6 months of purchase. If a client wishes to obtain a refund before services have been rendered, it will be issued – MINUS any transaction fees or costs. Exceptions strictly at the practitioner’s discretion.
13. Price paid for services is for the time allotted for sessions, during which I have the full and complete attention of the practitioner. A limited number of additional questions or concerns may be submitted via email or through the website booking interface, and will be answered in an average and reasonable time, as determined by the practitioner’s client load. If I, the client, desire or need interactions beyond the bounds of the paid sessions, that time is to be negotiated separately and is granted at the practitioners discretion.
14. I understand that my full identity will NOT be disclosed without my prior consent, and if the issues addressed during private sessions were to be shared with others it would only be in a general way for the purpose of educating them about these techniques. Content is to remain confidential under these conditions unless the practitioner is expressly given permission to share said information by the client.
15. I (the client) am aware that Jean Erickson is bound by the Ethics Guidelines of her certifications, and that in the event that information disclosed in a session reveals a present danger to the client or other individual, client should be aware that local disclosure laws (required reporting) may apply, and that said danger may be relayed to appropriate authorities.
16. In the event I am in a group session or class, which is being recorded on video and/or audio media, I agree that or Jean Erickson or Think. Feel. Change! Coaching may use my name, image, likeness and/or voice. I hereby release any and all claims regarding I may have in such recordings, including but not limited to copyright, trademark or service mark, royalties, reproductions, distributions, and public access. If I do not wish to be recorded in such a group session or class, it is my sole responsibility to inform or Jean Erickson or Think. Feel. Change! Coaching no less than 24 hours prior to the start of such group session or class.
17. If in the event a private session is recorded on written document, video or audio media, I understand that all records are confidential and will be for private use by Jean Erickson or made available to me for an additional fee. Any records of private sessions will not be viewed by anyone else without my prior written consent.
18. In the event that I or Jean Erickson or Think. Feel. Change! Coaching find it necessary to institute a proceeding in a court of law regarding this agreement, I agree that any such proceeding shall be brought in a court located in Oklahoma City, Oklahoma, and that this agreement shall be governed by the laws of the United States of America.
19. I acknowledge that I have read the above agreement, understand it completely, and agree with its terms and conditions.
20. I therefore retain Jean Erickson and voluntarily make and grant this Waiver and Assumption of Risk in favor of Jean Erickson of Think. Feel. Change! Coaching as consideration for monies, exchange or pro bono paid to Jean Erickson. By signing my name in the space within the line below I agree to this document. I understand that in order to PARTICIPATE in a session, class or webinar offered by Jean Erickson, I must agree to these terms and conditions,. My participation after receiving these terms and conditions means that I AGREE to the terms and conditions stated above.
Print out and sign this document and return to Jean Erickson (Think. Feel. Change! Coaching) prior to any session, class or webinar.
Alternate Electronic Signature: By typing my name, and the words “My Electronic Signature” in the space above this document attached to an email reply, I am consenting to the use of my electronic signature in lieu of an original signature on paper. An electronic signature is legally binding. I have the right to request a paper copy of any electronic record, or I may simply print this email out for my files.
My Signature _____________________________________________
City, State, Zip _____________________________________________
Cell Phone__________________ Home Phone _____________________