Client Informed Consent and Disclosure Statement
Agreement 

Theoretical Approach

My newest method of coaching and mind-body work is called Splankna. It is a biblically based protocol for energy psychology. (I work with people of all faiths, and you're under no obligation to follow the same beliefs in order for the protocol to work.) Energy psychology utilizes the same system in the body that acupuncture and chiropractic are based on to resolve unbalanced emotions that are stored in the body. “Energy Techniques” is a collective term used to refer to a variety of methods based on the use, modification, and manipulation of energy fields that look at imbalances within the person’s energy system as well as the energetic influence of thoughts, beliefs, and emotions on the body. The prevailing premise of the Energy Techniques is that the flow and balance of the body’s electromagnetic and more subtle energies are important for optimal physical, spiritual, and emotional functioning. Splankna is designed to help get to the origin of an emotional issue with the goal of rapidly desensitizing the emotional stress connected to a past event. Splankna incorporates elements from several newly-emerging energy-based psychotherapy, coaching, and self-help techniques, specifically Neuro-Emotional Technique, Thought Field Therapy, and Eye Movement Desensitization and Reprocessing. Prayer is intertwined with the protocol.

Although Energy Techniques like Splankna appear to have promising emotional, spiritual, and physical health benefits they have yet to be fully researched by the Western academic, medical, and psychological communities and, therefore, may be considered experimental. The Energy Techniques are self-regulated and they are considered alternative or complementary to the healing arts. Because Energy Techniques are relatively new healing approaches, the extent of their effectiveness, as well as their risks and benefits, are not fully known. If you ever have questions or concerns about the nature of the theories, methods, approaches and/or techniques I use, please feel free to ask me for further resources or references.
 

Outcome Expectations/Risk & Benefits

Please note that it is impossible to guarantee any specific results regarding your goals using any of the approaches I offer in my business and I cannot know how you will personally respond to any of the approaches. However, we will work together to achieve the best possible results for you. Our work together requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. You will have to work both in and out of our sessions. I will ask for your feedback and views on our work and its progress, and will expect you to respond openly and honestly. As with any intervention, there are risks associated with Energy Psychology. Risks might include remembering, talking about, or experiencing unpleasant events which results in uncomfortable levels of feelings like sadness, guilt, anxiety, anger, frustration, worry, etc, or experiencing anxiety, depression or insomnia, etc., or having difficulties with other people. Being confronted with your difficulties can be very challenging. Some changes may lead to what seems to be worsening circumstances or even losses (for example, performance work can not necessarily keep a marriage intact.).

In addition, if you choose to engage Splankna, emotional or physical sensations or additional unresolved memories may surface which could be perceived as negative side effects. You may experience some temporary emotional distress and physical discomfort related to prior life experiences.

We will need to specify methods, risks and benefits, the approximate time commitment involved, costs and other aspects of your particular situation. We will discuss a plan that seems most appropriate to help you reach your goals. However, regardless of our work together, you agree to take full responsibility for your self-care in the emotional, mental, physical, and spiritual dimensions of your life.
 

Other Important Information

Please be advised that I am not a licensed mental health professional and the approaches I offer are not intended to be a substitute for medical diagnosis or psychotherapy and they do not replace the services of a licensed physician or licensed psychotherapist. You agree and understand it is your responsibility to consult with your physician/psychiatrist for any specific medical problems. Further, you understand I may suggest you contact your physician or psychologist/psychiatrist if I believe it’s advisable. In addition, you understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing your physician or using prescribed medication, if any, without consulting with your physician/psychologist, even if after a session it appears and indicates that such medication or treatment is unnecessary.

Confidentiality will be maintained except for the following exceptions required by law to be reported: suspected harm to self or others, or suspected child or elder abuse.
 

Use of Touch

You understand the application of Splankna includes light touch on the back of the wrist. Touch can be a potential problem in a support relationship if you feel it is inappropriate. If you have any misgivings, doubts, or any negative reactions to any physical contact, it is very important that you let me know as soon as possible so that we can discuss your concerns. You understand you have a choice about these techniques that involve touch.
 

Education and Training

2018 – Trained in Level 1 Splankna Therapy, Miami, Florida. Splankna Practitioner Trainee.


Acknowledgment and Consent to Receive Services

By signing this agreement and any attachments hereto, you agree that I have disclosed to you sufficient information to enable you to decide to undergo or forgo any of the approaches and other services I offer. You understand that your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. Further, you understand that Splankna is a relatively new healing approach and the extent of its risks and benefits are not fully known and you agree to assume and accept full responsibility for all risks associated with using Splankna.

You represent that you’re competent and able to understand the nature and consequences of our proposed sessions and agree to be personally responsible for the fees related thereto. You have read and understand the above disclosure about the services offered by me and my training and education and you have discussed with me the nature of the services tobe provided, and except in the case of gross negligence or malpractice, agree to release, indemnify, hold harmless and defend Susan Kay Rasmussen from and against any and all claims or liability, of whatsoever kind or nature, which you, or your representatives, may have for any loss, damage, or injury, including without limitation, physical, emotional, mental, financial, or personal, arising out of or in connection with your sessions.


Please sign, date, check the box, and click on the "submit" button. Thank you!

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I have read and agree to honor the Splankna Agreement. *