Heal Now with Gary
Quantum Touch
Learn more about the Healing abilities of Quantum Touch
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initial following date
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Traumatic Memories
Divorce or Breakup
Anger / Frustration / Bitterness
Anxiety or Depression
Chronic Pain or Illness
Fears / Phobias
Grief
Lack of Joy
Procrastination
Self Esteem Issues
Sexual Problems
Success or Prosperity
Weight Issues
Other Issues Described Below
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Other Issues
Have you worked with someone else on these issues?
A Therapist
My Doctor
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Severe Depression
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Attempted Suicide
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Are you currently feeling suicidal?
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Do you have a medical or psychiatric issue I should know about?
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Do you have a history of or currently issues with substance abuse?
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Did you grow up with Siblings? What is the order of birth?
Did you have a strong religious upbringing?
Is there an issue, memory, situation or physical problem you would like us to start with?
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On a scale of 0 to 10, how strong is this issue for you?
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The following are optional questions
If you had to live your life over, what person or event would you like to skip?
What makes you angry and why?
Do any people or situations trigger a disproportionate reaction for you? (Fear, Anger, Sadness, Guilt?)
What is your biggest regret or sadness?
Who might be upset if you were completely healed?
What strengths or positive qualities are you bringing to our work together?
If our work was amazingly successful, what would change for you?
Is there anything else you would like Gary to know?
PLEASE COMPLETE THE INFORMED CONSENT PORTION BELOW
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I understand that Gary Ras is not a licensed therapist, psychologist or health care practitioner and offers EFT (Emotional Freedom Techniques) and Hacking Reality as a self-help educator only. (Please type your name below)
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I am aware that Gary Ras does not diagnose or treat illness or disease, and does not prescribe medications. I agree not to discontinue or change any medications I am taking while working with Gary Ras without consulting my doctor. (Please initial below)
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I understand that EFT and Hacking Reality are considered experimental procedures and are not a substitute for medical, psychological or psychiatric treatment or medications, and that it is recommended that I work with my primary caregiver for any condition I may have (Please initial below)
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I understand that EFT and Hacking Reality procedures may bring unresolved and distressing memories and related emotions and physical sensations into my awareness, and it is possible that disturbing material may continue to surface after a session and may require further work to resolve. (Please initial below)
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I also understand that previously traumatic memories may lose their emotional charge and this could adversely affect my ability to provide convincing legal testimony. (Please initial below)
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I understand that all information I share with Gary Ras is confidential and that no information will be released to any third party without my express written consent, with the following exceptions: 1) When there is imminent risk of danger to myself or another person. 2) When there is suspicion that a child, elder or dependent is being sexually or physically abused or is at risk of such abuse. 3) When a valid court order is issued for session records. (Please initial below)
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I understand that Gary Ras has a 24 hour cancellation policy and agree to pay for any booked sessions that have not been canceled 24 hours in advance. (Please initial below)
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I understand that session fees cover time spent with Gary only, with no guarantee of efficacy. I understand that my healing and progress toward my goals are ultimately up to me. While there's no expiration for package sessions, I acknowledge Gary offers no refunds for unused sessions after 90 days from purchase.
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I agree to take complete responsibility for my own comfort, health and well-being while working with Gary Ras. I agree that typing my name below is the electronic equivalent of my actual signature (Please initial below)
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