Practitioner Disclosure:

I, Maria D. Peralta, make the following disclosures: I am an employee of The Revival Studios. I am a professional who provides services that are considered life coaching and is not regulated by the state of Illinois. Each client will be interviewed and if it is determined that the services I provide can be of benefit, I will provide services in accordance with the education, training, and experience I have. I offer the following services:

Coaching: This “is a process that enables learning and development to occur and thus performance to improve. To be successful, a coach requires knowledge and understanding of the process as well as the variety of styles, skills, and techniques that are appropriate to the context in which the coaching takes place.” (Parsloe 1999) These services are not licensed by the state. The services do not include the practice of medicine or psychology or any other healing art since I am not a licensed physician.

Disclaimer
I understand that any information that The Revival Studios | Maria D. Peralta may provide is only general information and is not to be considered medical or legal advice. I understand that in the session we will use techniques that address the emotional components and energy system of the body. These methods include, but are not limited to Thought Field Therapy (TFT), Emotional Freedom Therapy (EFT), also known as Emotional Freedom Technique, which we will refer to as modalities. While there are increasing amounts of research showing the effectiveness of these techniques, they are not yet accepted as a mainstream method and therefore, is considered experimental.

Due to the experimental nature of these modalities, I agree to assume and accept full responsibility for any and all risks associated with utilizing EFT both in and out of a session with the practitioners of The Revival Studios and/or Maria D. Peralta. In no case are these modalities intended to diagnose, treat, cure or prevent any disease or psychological disorder. Neither of these techniques mentioned or any other energy-based technique that may be used in the session is intended as a substitute for medical or psychological treatment. Any stories or testimonials about these modalities are not to be considered a warranty, guarantee or prediction regarding any outcome of any individual using these techniques or modalities.

I understand that Maria D. Peralta is not a licensed therapist in the State of Illinois, but is certified as a practitioner in Emotional Freedom Therapy, Thought Field Therapy, and a Life Coach. Maria D. Peralta is providing these methods in a non-licensed coaching capacity and accepts no responsibility or liability whatsoever for the use or misuse of the information or techniques presented. I understand that I am strongly advised to seek professional advice as appropriate before making any health-related decisions. If I am on any medications, I understand that I am NOT to change any dosages and should consult my physician or the professional who prescribed my medications.

Informed Consent
Emotional Freedom Techniques or EFT is based upon the belief that the cause of negative emotions is a disturbance in the body’s energy systems. EFT and other similar methods address the energy system and are intended to decrease the impact of negative emotions upon the body. Energy methods are intended to complement, not replace, medical or psychological care.

Because these methods are relatively new, the extent and breadth of their effectiveness including risks and benefits are not fully known. While the evidence is mounting through scientific studies of the clinical significance of providing positive outcomes, each person responds differently and results vary from person to person in these techniques in addressing many emotion issues

Please sign below stating that you have been advised of the following:

*The intensity of previously vivid or traumatic memories may diminish. While this is considered a benefit this reaction may adversely impact your ability to provide compelling legal testimony regarding a traumatic incident.
*Reactions may surface during a session that you do not anticipate, including strong emotional or physical sensations or additional unresolved memories.
*Emotional material may continue to surface after a session and give an indication of other incidents that need to be addressed.
*For the purpose of Maria D. Peralta's own supervision and/or teaching, disguised case studies may be shared in those contexts.

I have thoroughly considered all of the above and have obtained whatever additional input and/or professional advice I deem necessary or appropriate to make an informed decision before commencing sessions utilizing EFT.

*I understand that gentle touch may be used, with my permission in a face to face session, for the purpose of therapeutic application.                                                                           *By my signature below, given freely and without pressure from any person, I consent to the use of EFT and other energy-based modalities within my sessions.
*I understand that Mitsuko Ito is not acting as a licensed medical practitioner, and will not be diagnosing or treating a specific disease.
*Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Maria D. Peralta or The Revival Studios from and against any and all claims or liability whatsoever kind or nature arising out of or in connection with my sessions.
 

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