Before your session

ERT waiver & intake

Two parts. The first is the waiver — what ERT involves, what will be touched, and your right to stop. The second asks how you've been doing, how stress tends to land in your body, and a little about where you come from.

Please complete it at least 24 hours before your session so Jane has time to read it properly.

About 10 minutes Confidential Most questions optional

Your information

By providing emergency contact information, you confirm that your emergency contact is aware you are participating in ERT and may be contacted in case of an emergency.

Before anything else — about your practitioner

Jane Savina is a practicing student of Emotional Release Therapy, training directly with Pat Jackman, founder of the Pat Jackman Method of Emotional Release Therapy. She is currently completing her practicum and is not yet certified in ERT.

What that means for you:

  • She is in training, not certified. She is working through a supervised curriculum toward full certification and has not yet received it.
  • Sessions are offered on a donation basis during this period, with a minimum of $40, in recognition of her training status.
  • You will be asked to complete a short feedback form after your session. It goes directly to Pat Jackman as part of Jane's practicum requirements, and it is how her hours count toward certification. You write it yourself, in your own words — Jane does not write it, edit it, or report on your session herself. It identifies you by first name or initials only. Submitting one is required, but you decide how much to say in it, and you may leave any question blank.
  • Nothing else leaves the room. Everything you tell Jane — on this form and in your session — stays with her. What Pat sees is only what you choose to write yourself.
  • She is not a licensed professional. Jane is not a therapist, psychologist, massage therapist, or medical professional, and does not diagnose or treat any condition.
  • You may ask at any time about her training status, the hours she has completed, or when she expects to certify. You are welcome to wait until she is certified if you would prefer.

Section 1 — Before we begin

Before your session, please watch videos of ERT being performed by Pat Jackman, founder of the Pat Jackman Method of Emotional Release Therapy at @jackman.pat on Instagram. These videos show sessions performed by Pat Jackman — not your practitioner — but give you an accurate picture of what ERT looks like and what to expect. If you have any questions about the content, please discuss them with Jane before signing this waiver.

Section 2 — Consent to touch

ERT involves the practitioner using their hands and fingers to apply pressure and manipulate specific points ("Activation") on the client's body. As a result, there may be pain and discomfort, as well as emotional expressions in the form of crying, sounds, screams, and vomiting.

Activation is most effective when performed directly on skin, but can be performed over thin clothing. Clothing covering the breasts as well as shorts, leggings, jeans, or pants must always be worn. The breasts, buttocks, and genital area are never activated. You will lie on a massage table with a bed sheet covering you except to access the areas being worked on.

Areas of the body that may be activated:

  • Front of body (required): Center point approximately two inches above the bottom of the sternum.
  • Front of body (possible): Two points along the sternum; six points on the chest along the collar bone; three points along the esophagus; four points on the face.
  • Back of body (required): Two points parallel to the spine roughly in line with the base of the shoulder blades.
  • Back of body (possible): Several points parallel to the spine from the waistline up; two points on either side of the neck; two to three points at the scapula; along the waistline following the top of the pelvic bone.
  • Legs (possible): Along the side of the thighs; along the calf muscle; at the Achilles tendon.

Which points are activated depends on available time, your tolerance, and your practitioner's evaluation during the session.

Do you wish the practitioner to wear latex gloves? (Check if yes — by checking you confirm no latex allergy.)

Section 3 — Your right to stop

You may ask the following at any time, which your practitioner will immediately honor:

  • To stop the session entirely.
  • To reduce the intensity of the Activation.

Please note that stopping adequate Activation of the required points, as determined by the practitioner, would also end the session.

Section 4 — Health confirmation

By initialing below, you confirm that you do not have any medical conditions or injuries — such as heart conditions, neurological disorders, or other contraindications — that could be negatively impacted by the session. If you are uncertain, you have consulted with a medical professional before participating.

Injuries, recent surgery, pregnancy, medications, or anywhere on the body that is currently tender or healing.

Section 5 — Disclaimer

While the term ERT stands for "Emotional Release Therapy," your practitioner is not representing themselves as a therapist, psychologist, massage therapist, or any other medical professional. The practitioner is not providing any therapy, advice, counseling, life coaching, treatment for mental illnesses, any other therapeutic treatment, or any medical or life advice. You are willingly participating in this session.

You understand and accept all risks associated with this voluntary session. You release the practitioner from any liability related to physical or emotional discomfort or pain during or after the session.

The second part — where you are

Most of this is about how you are right now. A few questions look backward, because the body usually picked up its habits somewhere — but you don't have to go into any of that here.

Answer what you can. One line is enough, and skipping a question is a perfectly good answer. Everything you write stays between you and Jane.

How you're doing lately

How do you handle stress these days? Check any that fit.

Where does stress show up in your body? Check any that fit.

When strong emotion does come up, what does your system do?

And what did it take to get there — or how easily did it come?
It doesn't need a name or a story. "I don't know, but it's heavy" is an answer.

What have you already tried? Check any that fit.

Where you come from

A few short questions about earlier on. Go as light or as deep as you want — a sentence is plenty, and you can leave any of it blank.

There's no right answer and no length requirement. Whatever comes first is usually the true one.

As a child, which emotions were allowed to be expressed in your home? Check any that fit.

Which of these did you tend to be, growing up?

"No one" is a real answer.

This session

Pacing, particular words, being checked in with, silence, going slow at the start.
Any area you don't want touched will not be touched. Sensitivities, injuries, and past experiences all belong here.

Electronic signature

By typing your full name below, you are signing this document electronically. You confirm that you are 18 years of age or older, that you have read all sections of this waiver, and that you are agreeing to all terms willingly and with full understanding.

Your submission is sent securely to your practitioner.
Questions before your session? Text (443) 254-6762.

Received 🌿

Thank you for completing your ERT waiver and intake. Jane will read it properly before your session — including whatever you wrote about where it started.
Questions? Text (443) 254-6762.

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