I hereby give my consent to the performance of Energy Medicine techniques and management of my condition(s). I understand that Energy Medicine is a holistic, complementary and integrative energy-based therapy that is accomplished through the use of contact and/or non-contact touch and a heart-centered state of being. Mary Sanders, MIM does not diagnose or treat disease and Mary Sanders, MIM is not a physician. These sessions are not a substitute for diagnosis or treatment from a qualified health practitioner for illnesses, injuries, or other medical conditions. Energy Medicine is not formally licensed or approved in many states but Aviva Integrative Health, LLC’s practice is guided by the Code of Ethics and Standards of Care located at www.drmarysanders.com/legal.
Basic Definition of Energy Medicine:
Energy Medicine is an energy therapy in which practitioners consciously use their hands in a heart-centered and intentional way to support and facilitate physical, emotional, mental and spiritual health and healing. The healing traditions of many cultures emphasize the importance of subtle energy systems that flow through and around the human body, affecting its health and vitality. Many of these traditions stress that balancing these energy fields can assist the body, mind and spirit in moving towards and maintaining wellness.
Description of a Session:
During a session (which can vary in length from thirty to sixty minutes), Mary Sanders, MIM will gently place hands on or above my fully clothed body noting any sensations or imbalances to assess the energy field. Mary Sanders, MIM will then choose an Energy Medicine technique that is appropriate for my needs. This may include light physical touch or sweeping hand motion above my body. There is a high likelihood that I will experience a relaxation response during the session. A feedback discussion will follow. People have many different responses to Energy Medicine. Some clients feel nothing at all. Others describe sensations of moving energy, deep relaxation, feelings of being supported and nurtured, or visions of images and colors. Some patients experience an emotional release such as tears; some have what they consider to be a spiritual experience or they may develop insight into specific areas of their lives.
Benefits of Energy Medicine:
Research studies suggest that Energy Medicine is effective for physical and mental relaxation, pain management, anxiety and stress reduction, and increasing one’s sense of vitality. Recipients of Energy Medicine typically report experiencing the relaxation response and often report an increased sense of well-being and peace. Many have reported positive experiences that have helped them better cope with illnesses, medical protocols for treatment of medical conditions and depression but Mary Sanders, MIM can make no specific claims regarding the results I may experience from an Energy Medicine session. Energy Medicine comprises noninvasive energetic techniques, still being researched by traditional science, and currently has no known detrimental side effects.
I understand that the practice of Energy Medicine, like the practice of all healing arts, is not an exact science, and I acknowledge that no guarantee can be given as to the results or outcome of my care. I have had an opportunity to discuss with Mary Sanders, MIM the nature and purpose of Energy Medicine. I understand and am informed that, as with the practice of all healing arts, Energy Medicine may carry some risks to treatment or limited benefits. I do not expect Mary Sanders, MIM to be able to anticipate and explain all risks and complications. I consent to rely on Mary Sanders, MIM’s best judgment, exercised during the course of treatment that is in my best interest, based upon the known facts.
I have read the above statement of consent. I have also had an opportunity to ask questions about my consent, and by signing below I agree to the above named Energy Medicine procedures to be administered by Mary Sanders, MIM. I intend this consent form to cover the entire course of treatment for my present conditions(s) and for any future condition(s) for which I seek treatment.
- PATIENT PLEASE REVIEW ● PRINT & SIGN NAME ●
I have read this informed consent document. I have discussed or been given the opportunity to discuss any questions or concerns with Mary Sanders and have had these questions or concerns answered to my satisfaction prior to my signing this informed consent document. I have made my decision voluntarily and freely.
PATIENT’S NAME (Print)________________________________________________ DATE OF BIRTH______________
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(PATIENT | GUARDIAN SIGNATURE) (DATE)