Declaration

EFT and AFT sessions are offered on the basis that you understand and agree to the following:

q  I understand that Mary Jones is not a medical doctor and has no medical qualifications.

q   I understand that Mary Jones’ training and qualifications are limited to the following:

• Licensed Practitioner of Meridian Therapies through the Association for Meridian Therapies
• EFT Certified (EFT Cert-I) through Gary Craig
• Practitioner of Attractor Field Techniques trained by Dr Kurt Ebert
• Licensed NLP Practitioner
• Personal Coach trained by the Coaches Training Institute

q   Where my condition involves medical or clinical symptoms I confirm that I have consulted a qualified doctor or medical specialist and have received a medical diagnosis prior to receiving EFT or AFT.

q   I understand that EFT and AFT do not directly treat any physical or medical condition, but are both designed to resolve emotional issues and/or alter belief patterns which may or may not be contributing to a physical condition. I therefore agree that by seeking EFT orAFT sessions I am not seeking treatment for any physical or medical condition but that my goal is to resolve emotional issues and/or alter my belief system, and that Mary Jones’ role in this is to guide me in the correct application of EFT and/or AFT.

q   I agree not to begin, alter or discontinue any prescribed medication or other treatment recommended by a doctor without first consulting my doctor.

q   I agree to take full responsibility for my emotional and physical wellbeing during the EFT/AFT session. I understand that I do not need to divulge any personal information that I do not wish to, and that I am free to decline to work on any issue that I do not wish to.

Do you have any history of epilepsy?                                                                         
(Epilepsy does not preclude using EFT, but a non-tapping variation may be used instead)

[  ] No                 [  ] Yes, currently            [  ] Yes, in the past  (How long ago?........................)

Are you currently being treated or under the care of a doctor or therapist for any clinically diagnosed psychological disturbance?
(e.g. Schizophrenia, Bipolar disorder, Disassociative disorder, clinical OCD)

[  ] No               [  ] Yes   (Please state:……………………………………………....)

If Yes, you may still receive EFT/AFT, but with the knowledge of your existing professional carer. Please give the name and contact details of your doctor or therapist so that I may contact them.

----------------------------------------------------------

----------------------------------------------------------

----------------------------------------------------------

I have read, understood and agree to the above.

Name  ……………………………….  Signed ………………………………..    Date ……….........