ERT Waiver · Primal Coherence

Section 1 — Before we begin

Before your session, please watch videos of ERT being performed by the creator of the modality 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.

I have viewed the ERT videos at @jackman.pat on Instagram, or I understand what ERT involves and have had all my questions answered by my practitioner.

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.)

Yes, please use latex gloves

I consent to direct-to-skin Activation as described above, and I understand which areas of my body may be worked on during the session.

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.

I understand my right to stop or modify the session at any time, and I understand that stopping Activation of required points ends 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.

I confirm I have no medical conditions or injuries that could be negatively impacted by an ERT session, or I have consulted with a medical professional and have been cleared to participate.

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.

I have read and understood the disclaimer above and voluntarily accept all risks associated with this session.

Your information

Full name *

Phone number *

Emergency contact name, phone & relation *

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.

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.

Type your full name to sign *

Date signed *

I confirm I am 18 years of age or older. By checking here, I consent to the use of my electronic signature in lieu of an original signature on paper. I confirm that all information provided is accurate and complete to the best of my knowledge.

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

Waiver received 🌿

Thank you for completing your ERT waiver. Jane will review it before your session.
Questions? Text (443) 254-6762.