©2019 by Christine Amala.

Client Application

Please Describe what you would like to gain from our working together?

Is there anything else you would like me to know?

Disclaimer and Informed Consent

 Christine Hayes Certified EFT/Tapping Practitioner & Life Coach

• I understand that Christine Hayes is a certified Emotional Freedom Techniques (EFT) practitioner & Life Coach. Her EFT/Tapping Certifications are from The Association for the Advancement of Meridian Energy Techniques International (AAMET). She is not a psychotherapist, psychologist, physician or other government licensed health care professional.

• I understand that Emotional Freedom Techniques (EFT)/Tapping is a relatively new experimental technique based on the ancient Chinese energy meridian system. It involves tapping on specific meridian points with the fingers while at the same time thinking about what is bothersome. Evidence is growing that the body’s electrical and subtle energies are involved in the experience of unwanted emotions and that stimulating the meridian points causes the energy disruption responsible for the negative emotion to be released. I understand no guarantee or prediction can be made regarding the results of using EFT.

• I understand that EFT is not used to diagnose, treat, cure, or prevent any disease or psychological/mental health disorders. Consequently, EFT sessions do not provide medical diagnoses, not do they offer cures. I understand that EFT is not meant to replace standard medical care and/or mental health counseling and agree to consult with my health care provider(s) regarding the appropriateness of my use before participating in EFT/Tapping sessions.

• I understand that it is recommended that I see a physician or other licensed health care professional for any physical or psychological ailment I may have. I understand that it is not recommend that I stop using any prescribed medicine or other kind of therapy that I may be using without consulting the appropriate licensed health care provider.

• I agree to take full responsibility for my well being, should I decide to learn the EFT/Tapping procedure as part of my work with Christine Hayes. I bear the responsibility for any decision I make based on my work with her.

• I have thoroughly considered all of the above and have obtained whatever additional input and/or professional advice I deemed necessary or appropriate about commencing sessions that utilize EFT/Tapping. My signature below is given freely and without pressure from any person, consents to the use of EFT in my sessions.

• I understand that fees are $135 per hour unless otherwise agreed. Sessions over one hour are charged on a prorated basis in 15- minute segments. I understand that payment is due at the time of my appointment, or prior to my appointment time if I am making my payment online, unless other arrangements have been made in advance.

• I understand that if I need to change my appointment time I am asked to give 48 hours notice. If less than 24- hour notice is given I will be charged the full fee for the session.

1) Have you been or are you currently under psychiatric care or in psychotherapy? If yes - why?

2) Are you currently on any medications? If yes, describe.