Bloss-OM LLC Client Consent Form

For Coaching with Jerrica Fritzley 

Tapping, Flower Essence and Energy Meditation Practitioner

Emotional Freedom Technique (EFT) and Energy Meditation are self help techniques. These techniques should be viewed as complementary to working with your therapist and/or physician. 

I do not diagnose or treat disease and I am not a physician or a mental health care provider. These sessions are not a substitute for diagnosis or treatment from a qualified health practitioner for illnesses, injuries, or other mental/medical conditions. My services are not licensed by the state of Idaho.

In the event of a crisis: I do not do crisis work. In the event of a crisis please call 9-1-1, go to your nearest hospital, call a  mental health care provider, or national suicide prevention lifeline (800)-273-8255. If you need a referral for a therapist or counselor, I will do my best to help find a service provider that can best serve you. 

Privacy: Your information will be kept private to the best of my ability. Notes are stored on my computer and deleted after 5 years of working together. My computer is password protected. I will never keep medical records or medical information.  

Serious Threat to Health or Safety: If I believe that you pose a clear and substantial risk of imminent serious harm to yourself or another person, I may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or your family to protect against such harm. If you communicate an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and I believe you have the intent and ability to carry out the threat, then I may call local authorities in your area. 

Minors: At least one parent or guardian must be involved in the minor child's sessions. Parents commit to a follow-up email after the minors session. At this time the parent(s) may ask questions while also reporting on the minors emotional well being after the session. Often in EFT & Energy Meditation there is a shift in one's nervous system which can leave a person feeling more tired as they integrate the new thought pattern. The minors personal shares will be kept confidential unless there is an immediate threat to the minors life or the information shared becomes out of scope for Jerrica Fritzley. At that time an appropriate referral is needed. Together the parent and practitioner (Jerrica Fritzley) will work to find the best care for the minor. 

Scope of work: If at any point Jerrica Fritzley feels the situation is out of range for her scope of work, a referral will be given to work with a licensed health care provider. In some cases, continuing to work together will be possible while working with a licensed therapist or counselor. Consult with your licensed healthcare provider to make an appropriate decision for the care you need. 

Techniques & Session(s): 

EFT: During a session I work with the client to help identify an issue(s) that the client would like to work on and develop an appropriate “setup” statement. I will then demonstrate and lead  the client through a series of tapping motions on acupressure points on the body, while repeating  the setup statement out loud. The combination of tapping and repeating the setup statement sends a calming signal to the amygdala, a part of the brain associated with the body’s fight and flight response and allows the brain to send calming signals to the rest of the body. The process often promotes a feeling of peace and general well being. EFT combines methods from exposure therapy, Chinese Medicine (acupuncture), and cognitive therapy into one method. 

Flower Essences: Are made by placing the flower from a plant or tree directly into a bowl of purified water. The water holding the flower essence is then preserved with an alcohol - often Brandy. The formula is then created with the 1-7 different flower essences and preserved once again by adding 1/3 brandy into a dropper bottle to create your custom formula. In the event alcohol is not perfered for the custom formula, Jerrica can use glycerine (a non alcoholic preservative) to make the formula. Please know and understand the essences Jerrica works with are originally made with a small amount of Brandy. 

The client agrees to inform Jerrica of any known allergies prior to Flower Essence creation and by signing of this contract agrees that Bloss-OM LLC and Jerrica Fritzley personally are not liable for any allergic reactions or other physical reactions that may occur.

Flower Essences are generally known to be safe. There is a possibility of an emotional release, which is generally gentle and found physically harmless. Flower Essences are not to be used as medicine or a substitute for medication. Jerrica endeavors to use the best practices while mixing the flower essence formulas to keep a high level of hygienic standard. They are not mixed in a commercial kitchen. But are safely made in a designated surface area free from other food and possible contaminants. If you have concerns please reach out directly to Jerrica and [email protected]  

Energy Meditation:  With Energy Meditation  Clients are guided to connect  with the subtle energy that runs through the body. Connecting with the body’s subtle energy allows the client to harmonize the spirit and body. During this portion of the session the client  simply closes their eyes and observes with the senses through intuition. 

Sessions are up to 90 minutes long, held over an internet platform, currently I am utilizing Zoom.  Depending on how the session is progressing I will/may suggest switching from Tapping to Energy Meditation or vice versa. Prior to termination of the session, I assist the client in feeling grounded and calm.

Benefits and risks: 

Benefits and clinical studies can be found at:  

https://www.eftuniverse.com/research-studies/eft-research

EFT often works quickly to resolve issue(s) that have been identified within just a few sessions. However, this is not always the case and issues may take a few sessions or longer to resolve. 

Tapping can bring clarity and neutrality to an  emotionally charged event. The client may experience feelings of  emotional freedom from the event. 

Emotions may come up as we focus on the negative while inviting acceptance to the situation. It is important to know we may talk about past events, but only as the client is willing and ready. The end result is often a feeling of peace and resolution as the client is given the opportunity to reprocess a past event from a new mindset. 

You may experience what is often referred to as “off-gassing” in the form of burping, sneezing, laughing, crying, checking out, getting tired, or perhaps needing to go to the bathroom. This is a sign that the method is working. It often passes quickly.  

Educational Training, credentials, experience:

Jerrica has studied with a master in Energy Meditation for over 8 years and has assisted for 3 of those years. Jerrica is a certified EFT Practitioner by Sonya Sophia’s School of Living Arts. And certified in Clinical EFT through EFT Universe with Dawson Church (the co-writer of the EFT manual). She is a graduate of LYT Yoga 200 hour teacher training program and Triveni Yoga (400+ hr YTT graduate). She is a trained mindfulness teacher for youth & has taught kids in the classroom. Jerrica has worked with clients for 4 years. Working with a variety of ages (11-50+).

FEES:   

All fees are due before the session begins and are non refundable. Transactions are done through the secure platform of HoneyBook. 

Packages: 

The Bloss-OM Package is $1229.00 pay in full. 

Payment plans are due every month, the same date of purchase. 

Payment plans are available up to 4 month installments of $307.25 a month 

Client agrees to make all payments on time through automatic bill pay through the online system Kajabi, a secure payment processor. 

Bloss-OM LLC and Jerrica Fritzley do not issue refunds and all payments must be paid for in full upon purchase 

Unless Jerrica is unable to provide services past a year long time period from purchase date  

Bloss-OM Package Includes: 

• 6 tapping sessions
• 1 Flower Essence Formulas 
• Breathwork video series
• Text message support during business hours 
• Completed within a 4 month container 

Scheduling appointment and Cancellation: 

Sessions are up to 60 minutes. To schedule. reschedule, or cancel your appointments do so through the online booking system Kajabi. If you cancel An appointment, I require clients to provide notice at least 24 hours before the session or the client forfeits the session.  If you are over 15 minutes late, I may cancel your appointment, and the session is also forfeited. I endeavor to begin and end sessions on time. However, in some circumstances, it is necessary to run over the scheduled appointment time. If I run more than 10 minutes late, you have the option to reschedule without penalty. 

I can be reached during office hours through text message at 650-823-8472 or email at [email protected]  in the case an urgent matter arises. Know these modalities are not encrypted and information can be easily obtained by third parties. It is important to only share non-personal information through these channels. 

Booking: 

All 6  tapping sessions are to be immediately booked and had within 3-4 months time 

in the event of an illness, discuss receiving an extension to 6 months - Only if discussed and agreed upon with & by Jerrica Fritzley who will send a new contract to be signed & updated 

Any remaining sessions thereafter will be forfeited after the 6 month deadline unless otherwise discussed & agreed upon.

We will endeavor to provide all 3 Flower Essences formulas within 4 months time.  Due to the nature of how often they are taken the client may be given the Essence up to the 6 month period.

CANCELLATION AND NO-SHOW APPOINTMENTS: You agree to the following:

To provide at least 24 hours’ notice of cancellation or rescheduling of an appointment. 

To foregit the appointment if canceled under 24 hours of the scheduled appointment time. 

To pay for each month's payment plan until full amount of $1229.00 is paid for or 4 payments of $307.25

If you are over 15 minutes late for an appointment, the appointment may be canceled, and the NO-SHOW forfeit applies. 

STATEMENTS: If you have a payment plan, an invoice will be emailed and made available to you each month. 

BILLING QUESTIONS: For problems involving payments, please contact me by email at [email protected]

Agreements: 

I understand that at any time I may end the session. If I am experiencing discomfort, I will verbally tell Jerrica who will then switch the method.  I agree to book and have the session(s) within 4 months time depending on new or return client, and the number of sessions purchased. I understand there is an expiration date 4 months  from purchase date. 

 I agree I must cancel 24 hours prior to the session or the full 90 minute session will be charged or forfeited. 

I have been informed that all client information and records are treated in a confidential manner. My experiences during these sessions are confidential subject to the usual exceptions governed by State or federal laws and regulations. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless both  Bloss-OM LLC and Jerrica Fritzley from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). 

My questions have been answered to my satisfaction regarding Jerrica Fritzley’s background, scope of work, and what I might expect from this session. I give my consent to receive EFT, Flower Essences and Energy Meditation from Bloss-OM LLC & Jerrica Fritzley  EFT, Flower Essence and Energy Mediation Practitioner.