Client Agreement for Services, Disclosures & Consent for Remote Energy Medicine Sessions

Practitioner Name and Credentials: C.M. Hardt aka Clarymond - Certified EFT Practitioner 

Practice Location:  Remote via Zoom 

Contact: info@mothercorps.com 1 310 403 4772

Session Information

Remote energy medicine services involve the use of secure interactive videoconferencing devices and equipment that enable the practitioner to deliver services to the client virtually when they are located at different sites. 

Sessions are 60 minutes long.

The fee per session is $200.00. Packages of 3 or more sessions are offered at a discount rate. 

C.M. Hardt is not a provider for any insurance carrier and upon request will provide an invoice that the client may submit.

• I understand that the same standard of care applies to a remote session as applies to an in-person visit.

• I understand that the laws that protect the privacy and confidentiality of personal information apply to remote sessions.

• I understand that I will not be physically in the same room as the practitioner. I will be notified of this, and my consent obtained for anyone other than the practitioner to be present or work with me.

• Risks to Confidentiality: I understand that as remote sessions take place outside of the practitioner’s office, there is potential for other people to overhear conversations if I am not in a private place during the session. The practitioner will take reasonable steps to ensure privacy. It is my responsibility to find a private place for the session where I will not be interrupted. I also understand that it is my responsibility to protect the privacy of our session on the device being used.

• Technology Issues: I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties. For example, technology may stop working during a session, other people might be able to get access to our private conversations, or stored data could be accessed by unauthorized people or companies. If it is determined that the video conferencing equipment or connection is not adequate, I understand that either the practitioner or I may discontinue the remote session and make other arrangements to complete the session. 

Definition of Energy Medicine

Energy Medicine is holistic integrative therapy intended to clear, balance and energize the human energy system in order to facilitate physical, emotional, mental, and spiritual self-healing.  

The trained practitioner uses various energy medicine techniques with heart-centered intention. Energy medicine is intended to complement and not replace any prescribed medical care. Practitioners do not diagnose conditions or prescribe treatment.

• I understand that C.M. Hardt is not a licensed therapist or health care practitioner and offers EFT (Emotional Freedom Techniques) and Matrix Reimprinting as a self-help educator. 

• I am aware that C.M. Hardt does not diagnose illness or disease, and does not prescribe medications. I agree to not discontinue or change any medications I am taking while working with C.M. Hardt without consulting my doctor.

• 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.

• 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.

• I understand that previously traumatic memories may lose their emotional charge and this could adversely affect my ability to provide convincing legal testimony.

• I understand that all information I share with C.M. Hardt 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

• I give C.M.Hardt permission to describe the details of my sessions to her colleagues and mentors for training or supervision purposes only, as long as my personal anonymity is strictly protected.

• I agree to take complete responsibility for my own comfort, health and well-being while working with C.M. Hardt.

Appointment Cancellation Policy

I agree to give a 24-hour notice if it is necessary for me to cancel an appointment. My practitioner reserves the right to charge me for the session if sufficient notice is not given.

Confidentiality

All client information and records are treated in a confidential manner and no information will be released to anyone without my prior written consent, except in situations governed by law.

Disclosures

• Energy Medicine practitioners do not diagnose conditions or prescribe treatments. 

• No specific claims will be made by the practitioner regarding results from the Energy Medicine sessions. 

• Goal(s) for our work together will be mutually identified as part of the assessment and clients have input in the goal-setting process.

Practitioner Liability Insurance: EMPA 

Hold Harmless Clause

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless,C.M. Hardt, from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).