I, the undersigned, understand that the SoundSelf, Reiki, and all other healing services provided by Elizabeth Keane of Earth Pulse Alchemy in any session given may involve a natural hands-on method of energy balancing or supportive mentoring for the purpose of pain management, stress reduction, and relaxation.

SoundSelf is a form of biofeedback in which expressing my voice into the headset is the mechanism that provides the responsive light, vibration, and sound responsive to my voice. The biofeedback is not traditional biofeedback in the sense that there is no measure of my heart rate but is rather my exploration of responsive rhythmic lights, vibration, and my voice echoed back with layered symphonic sounds. Biofeedback is a clinical tool that can offer many benefits but may cause Headaches, Dizziness, and Fatigue, and can bring up emotional material and stuck energy to be processed. Biofeedback with the immersive light experience is not recommended for anyone with epilepsy, extreme sensitivity to light, history of seizures or known seizure risk, heart concerns.

I also agree to inform my provider if I experience any recent feelings of dissociation or loss of time, mania, psychosis, manic episodes, severe depression, blood pressure concerns, migraines, breathing difficulties, current respiratory illness, pregnancy or breastfeeding, a difficult reaction to meditation, or a recent psychiatric crisis, or have been on any substances in the last 24 hours. I have told my facilitator about any physical injuries and medical, mental, or psychological conditions, and I will tell them if anything changes. I agree to consult my medical provider if I have a question about any of the symptoms named above and obtain verbal consent prior to receiving SoundSelf. 

This experience may feel as though being in a lucid waking dream or an altered state of consciousness and the grounding breath I will be instructed to use is an anchor I can use to ground in anything unpleasant. I understand that I may experience strong physical sensations and emotions, including tingling, numbness, lightheadedness, temperature changes, cramping in the hands or feet, shaking, crying, laughter, sound, memories, or deep stillness. These are common and usually temporary. I may also experience none of these. I understand I may stop the experience of SoundSelf at any time by removing my headphones or expressing I no longer wish to continue in any session.

Reiki is considered generally gentle though may cause tingling sensations, shifts in body or emotional awareness, shifts in personal or spiritual understandings, and movement and release of somatically stored energy in the body. I understand I may verbally withdraw consent for reiki, hands-on services, or SoundSelf at any time by expressing I do not wish to receive hands-on assisted reiki, energetic work, or SoundSelf biofeedback. I understand very clearly that these treatments are not intended as a substitute for medical or psychological care.

I understand that SoundSelf, Reiki, and Energy Healing practitioners do not diagnose conditions, nor do they prescribe medicines, nor interfere with the treatment of a licensed medical professional. I acknowledge that agreeing consent to receive a session or Energy work, SoundSelf biofeedback, and healing services are an adjunct to my ongoing care and does not make Elizabeth Keane my therapist or responsible for my health care in any way. It is recommended that I seek a licensed health care professional for any physical or psychological ailment I have.

I am participating voluntarily. I am in charge of my own breath and experience, and I can slow down, return to natural breathing, open my eyes, or stop at any time. I take full responsibility for my own physical, mental, and emotional experience during and after the session.

I further understand that Elizabeth Keane is a mandated reporter and is legally bound to report any expressed material of child or elder abuse, and a duty to warn any victims and law enforcement if there is reasonable suspicion of any one in imminent danger based on the information I share. My sensitive information may be discussed in a consultation setting for the purpose of debriefing unless I choose to sign a consent to release information for any other party.

I agree for Elizabeth Keane to contact my emergency contact provided below if I am incapacitated for any reason or under extreme emotional or medical duress. I understand to take it easy and move slowly and drink water following my session, and that energy and emotions may continue to move and release following my appointment. I agree Elizabeth Keane will check in with me via phone or in person one or a few days following my initial session.

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Printed Name & Signature Date

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Emergency Contact Name, Relationship, and Phone Number