Informed Consent and Client Agreement Form for EFT tapping and Acupressure Services

Welcome! This document contains important information about the professional services and business policies of Farfalla Integrative Health LLC (“Farfalla Integrative Health” or “the Company”). The purpose of this Informed Consent and Client Agreement Form (this “Agreement”) is to inform you about the nature of the services and their potential risks and benefits so you can make an informed choice about whether you’d like to work with the Company.

Please read this form carefully and sign it before your first session. You can contact Christine McDevitt at christine@farfallaintegrativehealth.com to discuss any questions or concerns you may have.

Disclaimer

The practitioner at Farfalla Integrative Health is not a psychotherapist, counselor, or medical doctor. The Company’s services are not intended to diagnose, cure, or treat medical or mental health conditions. The services may be appropriate for you in combination with medical or mental health care you are already receiving, but the services are not a replacement for any conventional medical or psychological care that may be needed if you have been diagnosed with a physical or mental health condition.

By signing this Agreement, you understand that the Company is not providing you with psychotherapy, counseling, or medical services. You agree to continue following any recommendations made by your healthcare providers and to seek their professional advice as appropriate before making any health decisions.

Services

There are different methods and modalities the Company may use to help you deal with the problems you hope to address. These methods include but are not limited to Emotional Freedom Techniques (otherwise known as EFT or “tapping”), acupressure, other cognitive-somatic energy modalities, guided meditation, and coaching.

These modalities call for your active participation. To get the most out of your work with the Company, you will need to spend time addressing your goals outside of your sessions. By entering this Agreement, you agree to engage in this process willingly. If you are not actively engaged in the process or the Company determines that sessions are not effective, the Company may terminate services.

The techniques your practitioner uses in her work are based both on neuroscience and on the premise that by promoting balance and flow in the body’s electromagnetic and subtle energies, health and well-being can be enhanced. This premise is rooted in ancient eastern medicine practices such as acupuncture.

The techniques used may involve certain positions or movements or touching, holding, tapping, pressing, or circling over specific areas of the body. The application of these methods is individualized to fit your specific needs.

There have been many clinical studies supporting the effectiveness of EFT and cognitive-somatic energy work, and the amount of scientific research in this area continues to grow. Research suggests that these methods work to shift the brain’s electrical and chemical processes in ways that support change.

Despite the growing body of research, cognitive-somatic energy work (including EFT) and acupressure have not yet been fully accepted by the mainstream medical and psychological communities. As such, they could be considered experimental. Your practitioner has received professional training in all the techniques used in her work and is happy to discuss them with you if you have any questions or concerns.

Potential Risks

If you are on blood-thinning medication, you may be at higher risk for bruising while tapping or pressing on your face or body. This risk can be reduced (but not eliminated) by reducing the pressure used for tapping and holding acupressure points. The practitioner will provide thorough instruction and guidance on proper techniques during your session. However, you are responsible for self-monitoring the amount of force you use on yourself. The Company is not responsible for any injuries or adverse effects that may result from your own contact with your body during or outside of the sessions.

You may temporarily experience uncomfortable or unusual physical sensations (e.g., heat, tension, tingling, etc.) at times during our work. Every person is different, and there is no way to predict what your experience will be like.

Because your work with the Company may involve remembering or discussing unpleasant aspects of your life, you may experience uncomfortable emotional sensations (e.g., sadness, anger, anxiety, guilt, shame, etc.). Unresolved memories may also surface. Emotional sensations may continue to arise after a session and could indicate other incidents that may need to be addressed.

It’s also possible that using EFT or cognitive-somatic energy work could result in the fading of details of previously vivid or traumatic memories. If you’re involved in a lawsuit that involves events related to these memories, using EFT or cognitive-somatic energy modalities could adversely affect your ability to provide legal testimony about those events that carries the same impact as it would without use of these modalities. By signing this agreement, you’re acknowledging that you’re aware of and understand this possibility. You also acknowledge that you have the right to discontinue use of EFT and other cognitive-somatic energy methods at any time.

By signing this Agreement, you assume and accept full responsibility for any and all risks associated with participating in and using the methods as part of your participation in the session(s) and any work you may choose to do using the methods outside of session times. You agree to forever fully release and hold the Company and its owners, employees, and affiliates harmless from and against any and all claims or liability of whatever kind which you might incur as a result of your participation in any session.

Potential Benefits

Most people who accept the potential risks find cognitive-somatic energy work (which includes EFT) and acupressure to be helpful. Reported benefits include, but are not limited to, lower feelings of stress or distress, shifts in perspective, lower pain levels, improved performance, and changes in undesirable behavior patterns.

Everyone’s experience is unique, and there is no way to predict what your experience will be. By signing this Agreement, you understand that while the Company strives to provide the best possible care and most people have positive results from sessions, there is no guarantee of specific results or outcomes.

Sessions

Specific information for EFT sessions

New client EFT sessions are 90 minutes long and include an initial assessment, instruction in proper technique, and work on your issue of choice. Follow-up EFT sessions range from 30 to 90 minutes (depending on option purchased). Sessions may take place either in person at Farfalla Integrative Health’s office in Lafayette Hill, PA or virtually via secure video conference.

During an EFT session, your practitioner will guide you through a process where you’ll lightly tap on specific acupressure points on your face and body with your fingertips while holding in mind an aspect of a memory, thought, sensation, or feeling. Typically, you’ll be repeating various phrases while you tap. Your practitioner will lead you through this process and tailor these phrases to your individual circumstances. The phrases will change throughout the session as well as from one session to the next. Your practitioner will also provide instruction for you to do work on your own as appropriate outside of your scheduled session times.

Specific information for acupressure sessions

New client acupressure sessions are 60 minutes long and include an initial assessment, instruction in proper technique (for virtual sessions), and work on your issue of choice. Follow up acupressure sessions last about 50 minutes.

Virtual sessions: During a virtual acupressure session, you’ll be fully dressed and either seated or lying down in a comfortable position with your camera positioned so the practitioner can see most, if not all, of your body. You and your practitioner will take a few minutes at the beginning to discuss your needs.

Your practitioner will then guide you through a series of acupoint combinations and instruct you on how to hold the points on your own body. Your practitioner will be with you on camera the entire session and will tell you when and how to move from one point to the next. She will instruct you in modifications for holding the points if needed. Should you notice sensations in your body while holding the points or have questions or concerns during the session, your practitioner will help you navigate whatever occurs.

By engaging in virtual services, you acknowledge that it is your responsibility to follow all instructions and directions provided by your practitioner during the virtual sessions.

In-person sessions: During an in-person acupressure session, you’ll be fully dressed (except for shoes) and lying comfortably face-up on a massage table. (Please note that an acupressure session is not a massage.) Your needs will be discussed at the beginning of the session.

Your practitioner will then hold a series of acupoint combinations on various areas of your body. If there are any areas you aren’t comfortable with your practitioner touching, let your practitioner know; she will always respect your wishes. While your practitioner will be checking in with you periodically while holding the points, talking during the session is always optional. Some people prefer to discuss what comes up for them as it occurs during the session. Others prefer to remain quiet. Either way is fine.

Issues Related to Technology

Farfalla Integrative Health is committed to maintaining the privacy and confidentiality of your sessions. Every effort will be made to ensure that your sessions take place in a secure and private location. For virtual sessions, the Company will utilize a secure internet connection and private space.

While the Company will take reasonable steps to protect your privacy, it is your responsibility to ensure that you are in a private space during virtual sessions where there is no potential for outsiders to watch or listen to your session.

You’re responsible for providing the necessary computer, telecommunications equipment, and internet access for your sessions; managing the security of information on your computer; and arranging a location with sufficient lighting and privacy so you won’t be distracted or interrupted and where others won’t overhear your conversation.

Despite the best efforts from both parties, there is always the risk of problems with technology (e.g., disruption or distortion of the video stream). Please do a technology check on your end prior to the start of a session. You and your practitioner will discuss a back-up plan before getting started in case you get disconnected.

You understand there is always the risk that the transmission of information could be interrupted by unauthorized persons, and the electronic storage of your information could be accessed by unauthorized persons despite use of high security measures. By signing this agreement, you agree to release the Company and its owners, employees, and affiliates from all liability in the event of such unauthorized access.

Please be aware that the Company does not record sessions and does not permit any audio or video recording of any session by any party involved. This prohibition applies to all devices and mediums. This is to ensure the privacy, confidentiality, and integrity of our work together. By signing this Agreement, you, as the client, explicitly agree that you will not attempt to record, in any form or via any device, any part of any session, whether in person or conducted through online platforms.

Communication

Effective and honest communication is crucial for the success of your work with the Company. It is important that you openly and respectfully share your thoughts, express concerns, and ask questions. It is your responsibility to inform your practitioner of any discomfort, concerns, or issues you may have during a session.

If your practitioner provides any instructions or suggestions, it is for a specific reason, but please feel free to seek clarification or ask questions if you have them. If you’re uncomfortable with anything the practitioner does or suggests, you have the right to stop the session at any point, and the practitioner will make necessary modifications. You always have the right to refuse any suggestions or request a change in focus or direction at any time.

EFT and cognitive-somatic energy work are not traditional talk-therapy techniques. It may be necessary at times during a session for your practitioner to respectfully interrupt you while you’re speaking. Please don’t be offended. For you to get the most out of your time together, the practitioner may need to cut a story short to address the information most relevant for the nature of the work.

Communications outside of session times: Office hours vary, and your practitioner is not always immediately available by email, phone, or text. If your practitioner is with a client, she does not answer the phone or respond to texts. Your practitioner checks her phone and email several times a day during the work week. If you leave a message, she will make every effort to respond within 24 hours except for weekends, holidays, or vacation.

Scope of Practice

There may be times when issues come up during sessions that are either outside of your practitioner’s professional scope of practice (e.g., issues which require a psychiatrist) or for which you would benefit from added support such as traditional talk therapy or counseling services.

If that type of situation occurs and you’re not already under the care of a mental health professional, you agree to seek appropriate mental health services. You understand that you are ultimately responsible for taking care of your own health and well-being.

By signing this Agreement, you’re indicating that you understand if you have a medical emergency, you should call 911 or go to the nearest emergency room. If you have suicidal thoughts or are experiencing an emotional crisis, you understand that you can call or text 988 to reach the Suicide & Crisis Lifeline for free mental health support 24 hours a day.

Duration of services

There is no prescribed formula to determine how many sessions will be most effective for you or how often those sessions should take place. The number of sessions needed to fully address an issue depends on the complexity of the issue and your willingness to work on it. You and your practitioner will discuss a plan for services, and in most cases, you ultimately decide how many sessions you need. However, the practitioner reserves the right to end a session prematurely and/or terminate services completely if any of the following occur:

  • The practitioner determines that she is unable, for any reason, to provide you with services in a professional manner. In this case, the Company will inform you of this decision and provide other options for practitioners who may better meet your needs.
  • Your practitioner experiences inappropriate, threatening, disrespectful, hostile, or offensive behavior from you or another person present with you at your appointment.
  • An unsafe situation arises for you or your practitioner.
  • Your practitioner suspects you’re under the influence of illegal drugs or alcohol during a session.

By signing this Agreement, you’re indicating that you understand that the circumstances listed above may result in a session being ended prematurely and/or in the termination of all services.

Financial

Each session must be paid for prior to the start of the visit. Payments can be made with cash (in person only), check, debit card, credit card, Venmo, or PayPal. If a check is returned due to insufficient funds or any other reason, a return check fee of $35.00 will be charged to cover the additional administrative costs incurred by Farfalla Integrative Health.

Session fees are non-refundable. There is one exception to this policy: if, prior to your first visit, the Company determines from your intake form and a discussion with you that your needs are outside of the practitioner’s scope of practice, the Company will refund your payment.

Sessions are valid for a period of three months from the date of purchase and are non-transferable to any other person.

Extended session fees: If a complex issue arises during a session and you’re nearing the end of that session, you may be able to extend the time for a prorated amount (determined by the type of session or package initially purchased). This option will only be offered if your practitioner has time available. The prorated amount will be due at the end of the session.

Cancellation policy: You must give at least 24 hours’ notice to cancel a session without financial penalty. If you cancel a session with less than 24 hours’ notice, you will forfeit that session; no refund will be provided. Exceptions to this policy may be made in certain instances of emergency or illness at the Company’s discretion.

No-show policy: If you schedule and pay for a session and fail to attend without providing prior notice, it will be considered a no-show. In the event of a no-show, you will forfeit the session; no refund will be provided. Exceptions to this policy may be made in extreme circumstances at the discretion of the Company.

Lateness policy: If you arrive late for your scheduled session, the time will not be extended. The missed time cannot be added onto a future session.

Policy for prematurely terminated sessions: If, at any point during a session, your practitioner suspects you are under the influence of illegal drugs or alcohol, an unsafe situation arises, or your practitioner is threatened or harassed by you or another person present during your appointment, she reserves the right to refuse or end that session prematurely. Should this occur, your payment for the session won’t be refunded.

Privacy and Confidentiality

Farfalla Integrative Health maintains records of all sessions and interactions with you. Access to these records is limited to authorized personnel only. The Company may utilize an electronic recordkeeping system for the storage and maintenance of client records. The Company will take reasonable measures to protect the confidentiality, integrity, and security of all client records.

Anything that occurs during your sessions is kept confidential. The Company will always act to protect your privacy. There are several types of situations, however, where confidentiality cannot be maintained.

  • The practitioner is considered a mandated reporter according to Pennsylvania law. If she suspects abuse (sexual, physical, emotional) or neglect of a child (anyone under age 18), an elderly person, or an incapacitated adult, she is required by law to report it to the authorities.
  • If your practitioner believes you’re in imminent danger of harming yourself, she may legally contact a local crisis team, an emergency contact, and/or the police to ensure your protection.
  • If your practitioner believes you’re threatening serious bodily harm to another individual, she is required to take protective action. This may include notifying the potential victim and/or contacting the police.
  • If there is any legal action forcing Farfalla Integrative Health or any of its representatives to reveal your personal information, or if the law otherwise requires the Company to reveal your personal information, the Company will:
    • Quickly inform you of the legal action or requirement, unless doing so would break a law or a government order. The Company will consider any time constraints it may have for taking action to prevent the sharing of your information or to protect the confidentiality of any information that is shared; and
    • Work with you in any action you take to stop the sharing of your information or to protect the confidentiality of any information that is shared.

Dispute Resolution

Should any disagreements or issues arise related to this Agreement, including any questions about its meaning, validity, or termination, that the Parties cannot resolve on their own, the Parties will try to resolve them first through mediation. You and the Company will select a mediator you both agree on and participate in mediation sessions to honestly try to resolve the issue in good faith. If the Parties cannot fix the problem through mediation within a reasonable time, either party may proceed with arbitration. The arbitration will follow the rules of the American Arbitration Association. The decision made by the arbitrator is final. Each party will pay its own costs and expenses related to the mediation and arbitration, including lawyers’ fees. This Agreement is governed by the laws of the Commonwealth of Pennsylvania.

Acceptance of risk and agreement with terms

You agree that you are voluntarily choosing to participate in sessions offered by the Company, and you acknowledge that there might be a risk of injury or damage during a session, whether the session is done in person or virtually. The injury or damage might occur while using the premises, facility, or equipment, or from the negligence, whether unintentional or not, of Farfalla Integrative Health or any of its affiliates, employees, agents, representatives, successors, and assigns. You understand that this risk is part of any activity, program, instruction, or session.

By signing this Agreement, you hereby agree on behalf of yourself and all your personal representatives, heirs, executors, administrators, agents, and assigns to indemnify and hold harmless the Company from any loss, liability, damage, or costs that the Company may incur due to the services provided to you by the Company.

Your signature below indicates that you have read this Agreement in its entirety (or had it read to you), understand the information fully, have discussed any questions or matters of concern with Christine McDevitt, agree to abide by the Agreement’s terms, and agree that you have also received and reviewed the Notice of Privacy Practices.

By executing this Agreement electronically, you acknowledge and agree that your electronic signature is the legal equivalent of your handwritten signature.

Client’s Signature: _________________________________________________

Client’s Name: ______________________________________________

Date: ____________________