LIQUID MIND LLC Emotional Release Therapy Waiver, Informed Consent & Client Intake This form explains what Emotional Release Therapy (ERT) may involve, including physical touch, emotional expression, your choices during the session, and important health and consent information. It also helps me understand what you would like support with. You do not need to share detailed trauma stories or disclose anything you do not want to discuss. 01 Your Information Full legal name * Preferred name Date of birth * Date of upcoming session Phone number * Email address * How did you hear about Liquid Mind / ERT? Have you experienced Emotional Release Therapy before? Yes No Emergency Contact Name * Phone number * Relationship to you * By providing an emergency contact, you authorize Liquid Mind LLC to contact this person if a medical or safety emergency occurs during your appointment. 02 Informed Consent About Your Practitioner Your practitioner, Login Violette, is an Arizona Licensed Massage Therapist and Certified Emotional Release Therapy Practitioner trained in the Pat Jackman Method of Emotional Release Therapy. Login also incorporates training and experience in trauma-informed bodywork, guided breathwork, somatic awareness, emotional processing, nervous-system support, and somatic parts work. Emotional Release Therapy and somatic bodywork are intended to support greater body awareness, emotional expression, relaxation, and mind-body connection. ERT is not psychotherapy. Although emotional experiences, memories, thoughts, or sensations may arise during a session, ERT does not diagnose or treat mental-health disorders and is not a replacement for psychotherapy, psychiatric care, medical treatment, or other licensed healthcare. When appropriate, you may be encouraged to seek support from a qualified healthcare professional. I understand the nature and scope of the services offered by Liquid Mind LLC and understand that ERT is not psychotherapy or medical treatment. * What an ERT Session May Involve Therapeutic and activating touch Sustained or focused pressure to specific areas of the body Guided breathing and body-awareness exercises Verbal guidance and emotional exploration Identification of sensations, emotions, protective patterns, or internal parts Opportunities for emotional expression Periods of quiet or integration Physical and emotional experiences vary considerably from person to person. You may experience pressure, tenderness, discomfort, warmth, shaking, tingling, changes in breathing, muscular movement, fatigue, relaxation, crying, laughter, anger, fear, grief, vocal expression, memories, imagery, or other spontaneous reactions. None of these responses are required for a session to be beneficial, and you are never expected or pressured to produce an emotional release. I understand that physical sensations and emotional responses may arise during ERT and that my experience may differ from another person's experience. * 03 Consent to Touch ERT may involve the practitioner using their hands or fingers to apply intentional pressure or therapeutic touch to specific areas of the body. Head, face & jaw Neck Shoulders & upper back Arms & hands Upper chest & collarbone Sternum area Abdomen Back Hips & outer pelvic region Legs, calves, ankles & feet The specific areas addressed will depend upon your needs, comfort level, session goals, physical condition, and the practitioner's professional judgment. Breasts, genitals, and other intimate areas are not included in ERT activation or treatment. Appropriate clothing and/or draping will be maintained in accordance with professional massage-therapy standards. Some techniques may be performed directly on the skin when appropriate, while others may be performed through clothing or draping. I consent to appropriate therapeutic and activating touch as described above. * I understand that I may decline touch to any area of my body at any time. * Your Body, Your Choice Consent is ongoing. Agreeing to participate in a session does not mean you surrender control over what happens to your body. At any time you may ask to pause, stop completely, change positions, reduce pressure or intensity, avoid a particular area, receive more explanation, take a break, discontinue a technique, or end the session. You do not need to justify or explain your decision. Your practitioner may also modify or discontinue a technique if continuing would be inappropriate or unsafe. I understand that I remain in control of my participation throughout my session and may change or withdraw consent at any time. * 04 Health & Safety Information Because ERT may include sustained pressure, bodywork, changes in breathing, and emotional activation, please check anything that currently applies or that you have recently experienced. Health considerations Pregnancy or possibility of pregnancy Recent surgery Recent injury Fracture or significant sprain Cardiovascular condition High or uncontrolled blood pressure Neurological condition Seizure disorder Fainting / unexplained loss of consciousness Blood-clotting disorder History of blood clots / DVT Osteoporosis Active infection or fever Significant respiratory condition Healing wound or skin condition Chronic pain condition Medical treatment that may affect bodywork Relevant medication Other relevant condition None of the above Please explain anything checked above Do you currently have any areas of pain, injury, tenderness, numbness, inflammation, or physical sensitivity? Are you currently pregnant or could you be pregnant? Yes No Unsure Prefer not to answer Are you currently taking medications that may be relevant to your session? Liquid Mind LLC does not diagnose medical conditions and cannot determine whether ERT is medically appropriate for every individual. If you have a medical condition, recent injury, pregnancy, or other concern that could make bodywork unsafe, you may need clearance from an appropriate healthcare professional before participating. I have disclosed relevant health information to the best of my knowledge and will inform my practitioner if my health status changes. * 05 Emotional Safety, Expectations & Assumption of Risk Emotional & Psychological Safety ERT can sometimes bring attention to emotions, memories, sensations, or experiences that feel intense. Your practitioner will support you within the scope of ERT and bodywork; however, ERT is not crisis counseling or psychotherapy. If you are currently experiencing a psychiatric emergency, active suicidal intent, severe psychological instability, or another crisis requiring immediate mental-health intervention, ERT may not be an appropriate substitute for clinical care. I understand that ERT may bring up emotionally intense material and that I am responsible for communicating when I need to slow down, pause, or stop. * I understand that I may seek additional support from a licensed mental-health or medical professional when appropriate. * Results & Expectations People seek ERT for many different reasons and experiences vary. No particular emotional, psychological, physical, spiritual, or health result can be guaranteed. Liquid Mind LLC does not promise that ERT will cure, resolve, release, or treat any specific medical or mental-health condition. I understand that individual responses to ERT vary and no specific outcome has been promised or guaranteed. * Assumption of Risk & Release I understand that bodywork and emotionally focused somatic practices may involve temporary physical tenderness, emotional discomfort, fatigue, soreness, or other reactions during or following a session. I voluntarily choose to participate after having the opportunity to ask questions about the nature of the services. To the extent permitted by applicable law, I acknowledge and voluntarily assume the ordinary risks associated with participating in these services. This acknowledgment does not waive any rights that cannot legally be waived. I have read and understand the information above and voluntarily choose to participate. * 06 Client Intake What is bringing you to Emotional Release Therapy right now? What are you hoping to experience, understand, process, reconnect with, or let go of through this work? When you're stressed or overwhelmed, what tends to happen? Check anything that feels familiar. I keep pushing through I become extremely productive or busy I overthink or analyze everything I shut down or withdraw I become irritable or angry I feel anxious or restless I feel numb or disconnected I distract myself I turn toward food I turn toward substances or other numbing behaviors I exercise or move my body I cry I talk with someone I don't realize I'm stressed until my body reacts Other Anything you would add? Where do you tend to hold stress, tension, or emotion physically? Jaw / face Throat Neck Shoulders Chest Abdomen / stomach Upper back Lower back Hips Pelvic area Arms / hands Legs / feet Headaches / head tension Sleep disturbances Difficulty noticing sensations in my body Other Your Relationship With Emotion When strong emotions arise, what do you usually notice yourself doing? Crying Holding it in Becoming angry Going numb Freezing Disconnecting from my body Laughing or making jokes Trying to intellectually understand it Distracting myself Leaving the situation Feeling overwhelmed Reaching out for support I rarely feel strong emotions I'm not sure Do you feel comfortable crying or expressing emotion in front of another person? Yes Sometimes Rarely No I'm not sure When was the last time you remember allowing yourself to fully feel an emotion rather than trying to change or suppress it? Is there anything you've been carrying that you're ready to explore differently? You do not need to explain the entire story. What You've Already Tried Have you previously explored any of the following? Psychotherapy / counseling Trauma-focused therapy Somatic therapy / somatic practices Massage / bodywork Breathwork Meditation Yoga Energy work Support groups / recovery programs Medication Coaching Other This is my first experience with this type of work What has been helpful for you? What hasn't felt helpful? 07 Earlier Experiences Optional You never need to disclose details of traumatic experiences in order to receive ERT. How would you describe the emotional environment you grew up in? Growing up, which emotions felt safe or acceptable to express? Happiness / excitement Sadness / crying Anger Fear Frustration Needing comfort Asking for help Disagreeing Being loud / playful Very few emotions felt safe I'm not sure Which role sounds most familiar from childhood? The responsible one The caretaker The peacekeeper The high achiever The strong one The quiet / invisible one The funny one The rebellious one The one who tried not to need anything None of these I'm not sure When you were scared, hurt, or overwhelmed as a child, who could you go to for comfort? 08 Touch & Session Preferences Is there anywhere on your body that you DO NOT want touched or worked with? Is there anything about touch that would help me support you more comfortably? For example: asking before touching certain areas, explaining what I am doing, slower pacing, lighter pressure, avoiding unexpected touch, etc. When emotions become intense, what tends to help you feel supported? Being reminded to breathe Quiet presence Verbal reassurance Being asked questions Slowing down Taking a pause Having things explained to me Space / less talking I'm not sure yet Other Is there anything you are nervous or hesitant about regarding ERT? What would help you feel safe and supported during your session? Is there anything else you would like me to know before we work together? 09 Acknowledgment & Electronic Signature By signing below, I confirm that: I am at least 18 years old. I have read this form and had the opportunity to ask questions. I understand the general nature of Emotional Release Therapy and somatic bodywork. I understand that ERT is not psychotherapy, medical treatment, or a substitute for appropriate healthcare. I understand that emotional and physical responses may occur. I understand that consent is ongoing and I may pause, modify, or stop the session at any time. I have provided relevant health information honestly to the best of my knowledge. I voluntarily consent to participate. Full legal name / electronic signature * Date * By checking this box and entering my name above, I agree that my electronic signature has the same intent as my handwritten signature and confirm that I have read and voluntarily agreed to this form. * Submit Consent & Intake Form Thank you for taking the time to complete your intake. Your responses will be reviewed before your session so we can spend less time on paperwork and more time creating a session that feels intentional, collaborative, and supportive.
