Intake and Consent Forms Ready to Tap? Fill out my confidential Intake and Consent Forms to Get Started Informed Consent FormTappingwithTom.comI understand that Tom Wallace is not a licensed therapist, psychologist or health care practitioner and offers EFT (emotional freedom techniques) as a self-help educator only. *0 / 3I am aware that Tom Wallace does not diagnose illness or disease and does not prescribe medications. I agree not to discontinue or change any medications I am taking while working with Tom Wallace without consulting my doctor. *0 / 3I understand that EFT is considered an experimental procedure and is not a substitute for medical, psychological or psychiatric treatment or medications, and that it is recommended that I currently work with my primary caregiver for any condition I may have.0 / 3I understand that before beginning work together, Tom and I will discuss any medical or psychiatric conditions I may have, or may have had in the past, including suicidal ideation.0 / 3I understand that EFT procedures may bring unresolved and distressing memories and related emotions and physical sensations into my awareness, and it is possible that disturbing material may continue to surface after a session and require further work. *0 / 3I also understand that previously traumatic memories may lose their emotional charge, and this could adversely affect my ability to provide convincing legal testimony. *0 / 3I understand that all information I share with Tom Wallace is confidential and that no information will be released to any third party without my express written consent, with the following exceptions: 1) When there is imminent risk of danger to myself or another person; 2) When there is evidence that a child, elder or disabled person is being sexually or physically abused or is at risk of such abuse; 3) When a valid court order is issued for session records *0 / 3I give Tom Wallace permission to describe the details of my sessions to his colleagues and mentors for training or supervision purposes only, as long as my personal anonymity is strictly protected. *0 / 3I understand that Tom Wallace has a 24-hour cancellation policy and agree to pay for any booked sessions that have not been canceled 24 hours in advance. *0 / 3I agree to take complete responsibility for my own comfort, health and well-being while working with Tom Wallace. *0 / 3I certify that I am at least 18 years of age. *0 / 3I agree that typing in my name below is the electronic equivalent of my actual signature. *0 / 3Client Signature (Typing your name equals consent.)Send Consent Form
