I, (please put your name in this box) 

have been advised and understand that a component of the treatment I will receive may utilize a technique called energy checking and involve work with  energy treatment points.

Energy checking is an assessment tool for determining how energy patterns affecting my body and mind may be related to the problems I wish to address in pursuing treatment with my psychotherapist. The technique involves my psychotherapist applying physical pressure that will determine if a specific muscle stays firm or loses strength when I bring to mind a particular thought, emotion, or problem state and resist the pressure.  The outcome, as indicated by the relative firmness maintained by the muscle, provides information to both my therapist and myself about emotional dimensions of my problems that may not be available to me through introspection.  Based partially on this information, my therapist will advise me on which energy points may best be used in helping me achieve my treatment goals.

Energy treatment points, adapted from the practice of acupressure, are located on the surface of the skin throughout the body and can be stimulated for the purpose of correcting disturbed energy patterns that might underlie emotional and psychological problems.  Stimulation may include touching, rubbing, or tapping the point.  In most instances, I will be instructed on how to stimulate the appropriate points myself.  In some instances, my therapist may ask my consent to directly work with specific treatment points.

I understand that the use of energy checking and energy treatment points within the field of psychotherapy is a new development and that at this time there is very little published research in established scientific journals investigating these methods. While clinical reports of successful outcomes using these methods do exist in the published literature of the field known as energy psychology, and the methods are being developed and refined under the auspices of organizations such as the Association for Comprehensive Energy Psychology, I understand that clinical reports do not constitute conclusive scientific evidence.  I further understand that even if the clinical effectiveness of these methods is scientifically established, results will vary from person to person.

I have thoroughly considered all of the above and have obtained whatever additional input and/or professional advice I deemed necessary or appropriate about commencing treatment that utilizes energy checking and energy treatment points.  By my signature below, given freely and without pressure from any person, I consent to the use of these methods in my treatment.

By submitting the consent form, you are stating that you have read, understand, and agree with this consent.