Client Informed Consent Form PhoneThis field is for validation purposes and should be left unchanged.Name(Required) First Last Consent(Required) I am aware that Cyrus Bush 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 Cyrus Bush without consulting my doctor.Consent(Required) I understand that EFT and Matrix Reimprinting are considered experimental procedures and are 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.Consent(Required) I understand that EFT and Matrix Reimprinting 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.Consent(Required) I also understand that previously traumatic memories may lose their emotional charge and this could adversely affect my ability to provide convincing legal testimony.Consent(Required) I understand that all information I share with Cyrus Bush is confidential and that no information will be released to any third party without my express written consent, with the following exceptions: When there is imminent risk of danger to myself 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 When a valid court order is issued for session records.Consent(Required) I understand that Cyrus Bush has a 24-hour cancellation policy and agree to pay for any booked sessions that have not been canceled 24 hours in advance.I agree to take complete responsibility for my own comfort, health and well-being while working with Cyrus Bush. I agree that the checkboxes above are my agreement of the terms. I agree that typing or signing my name below is the electronic equivalent of my actual signature.Date Consent Signed(Required) MM slash DD slash YYYY Signature(Required)
