Informed Consent & Waiver

    Thanks for your responses! I've received your intake form and am looking forward to our time together.

    In order to receive EFT or Coaching during our consult and/or subsequent sessions, please read and sign below. This is not a contract to continue working with me beyond your consult. It's just all the standard waiver stuff that my insurance requires in order to do EFT / Coaching with you, whether that's just a consult, or future paid sessions.



    Informed Consent & Waiver

    Your email address (required to send you a copy of this form):

    Missed Appointments and Cancellation Policy

    Booked appointments are time set aside just for you. Please give me at least 24 hours notice to cancel your appointment. Cancellations made within 24 hours of your appointment (up to four hours before your scheduled time) will be charged a $50 cancellation fee. For consults, I will use your deposit to pay the cancellation fee. Exceptions will be made for extenuating circumstances.

    An appointment is considered missed if you are more than 15 minutes late for your appointment, or you cancel 4 hours or less before your appointment time. Missed appointments will be charged the full rate. For consults, your deposit will not be returned. Exceptions will be made for extenuating circumstances.

    Please initial - I have read, understand and agree to the above:

    Privacy & Sharing of Information

    Notes taken during session are stored in a locked cabinet that only I have access to, and I do not share the details of my appointment calendar with anyone. I will never release your personal information or session records to a third party without your written consent, with the following exceptions:

    • When there is imminent risk of harm to yourself or another person;

    • When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse; and

    • When a valid court order is issued for session records.

    • I may occasionally find it helpful to consult other professionals about a client in order to provide a higher degree of service and expertise. During such a consultation, I will take all reasonable precautions to protect your identity, and will never share anything that I do not feel is absolutely necessary for the consultant to know. The consultant is also bound to keep the information confidential. You understand that unless you object, I will not tell you about these consultations unless I feel that it is important to our work together.

    Please be aware that, as with all electronic communication, it is not possible to completely secure all communications sent between us. There is a small risk that our communications could be intercepted, or that back up copies of our electronic communications could be unknowingly stored on a computer even after online versions (such as emails) have been deleted.

    Please initial - I have read, understand and agree to the above:

    Scope of Practice

    I am not a licensed therapist or psychologist. While Emotional Freedom Techniques and Coaching may augment the care of such professionals, it is not a replacement for qualified medical and psychiatric care.

    You agree not to discontinue or change any medications you are taking while working with me without consulting your doctor.

    You understand that in certain circumstances, it may be a condition that you work with a psychologist in order to continue EFT Coaching. I will also refer you to a qualified medical or mental health professional if I feel your concerns or symptoms are beyond my scope as an EFT Practitioner / Coach.

    Please initial - I have read, understand and agree to the above:

    Informed Consent to Receive EFT Tapping & Coaching

    EMOTIONAL FREEDOM TECHNIQUES (EFT/TAPPING)

    I offer EFT Tapping, a tool used for the relief of physical, emotional and mental discomforts, and also for creating dramatic improvements in peak performance issues. Although the use of EFT is producing excellent results and has gained a solid reputation based on scientific studies and research, the actual mechanism of how it works is not fully known at this time. Since it has not yet been fully adopted by conventional Western academic, medical and psychological communities, it may be considered experimental in nature. It is a relatively new approach and the extent of its effectiveness and its risks and benefits are also not fully known.

    Gentle tapping stimulation of acupressure points located on the surface of the face and body is paired with mental activation of disturbing content or desired outcomes. This can shift the brain’s electrochemistry to enhance performance and wellbeing.

    The following changes may also be observed following an EFT Tapping session:

    • The intensity of previously vivid or traumatic memories may diminish. This could adversely impact your ability to provide legal testimony regarding a traumatic incident, and affect your eligibility for disability or injury-related benefits as you may no longer meet the diagnostic criteria for a particular illness or disease;
    • Reactions may surface during sessions that are unanticipated, including strong emotions or physical sensations or additional unresolved memories, which may be interpreted as a negative reaction;
    • Emotional material and memories may continue to surface after a session, and give indication of other incidents that may need to be addressed.

    You understand that even as the effectiveness of these methods is scientifically established, results will vary from person to person.

    As a result, you agree to take full responsibility for your actions, as well as your mental, physical and emotional wellbeing before, during and after working with me. You understand that you may stop working with me at any time.

    If you have any questions or concerns about the use of EFT Tapping, please email or phone me and I will be happy to discuss with you.

    You arm that you have had sufficient information provided to you to make an informed decision around your use of EFT, and that you have had an opportunity to consult with me around the information provided. You hereby consent to receiving EFT Tapping from me.

    COACHING

    Coaching techniques are taught to EFT practitioners in the course of their study to augment the effectiveness of EFT. I have received such training and use Coaching for these purposes. I am not a certified Life Coach.

    Our Coaching work will take place within a peer-to-peer relationship, where new insights are fostered, goals are set, and appropriate tasks (“homework”) are agreed upon by the client in consultation with the Coach. You are considered the expert on your life.

    As the Client, you are expected to take your goals seriously, to complete the tasks you agreed to, and to purposefully work toward your goals. As the Client, you understand that I cannot create change or success for you, and so you agree to take full responsibility for your progress before, during, and after receiving services from me. You understand that any decisions you make as a result of working with me are your complete responsibility.

    If you have any questions or concerns about the use of Coaching, please email or phone me and I will be happy to discuss with you.

    You agree you have had sufficient information provided to you, as well as the opportunity to ask questions, to give your informed consent. You hereby give such consent to me to provide Coaching to you.

    Please initial - I have read, understand and agree to the above:

    Waiver & Release of Liability

    In attending any session with Jessica Dorzinsky, you agree to assume total responsibility for your own safety and well-being. You release from all liability and hold harmless Jessica Dorzinsky and her agents from any and all legal responsibility for any injury, illness, accident, loss, or other misfortune that may occur in connection with your participation in, or attendance at, sessions, workshops, activities, events, or visits, facilitated by Jessica Dorzinsky.

    Please initial - I have read, understand and agree to the above:

    Please type your full name:

    Sign here with your mouse or finger: