ERT Intake Form

Your information

Full name *

What you like to be called

Date of birth *

Phone *

Email *

Session date, if booked

How did you find ERT?

Have you done ERT before?

Emergency contact name *

Emergency contact phone *

Relationship to you *

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.

About your practitioner

Jane Savina trained in Emotional Release Therapy directly with Pat Jackman, who founded the Pat Jackman Method. She is completing her practicum toward certification.

Sessions are donation-based.
At the end of your session, Jane will hand you a short feedback form. You write it in your own words, and it is shared with Pat as part of Jane’s training — identified by first name or initials only. Say as much or as little as you like.
Nothing else leaves the room. What Pat sees is only what you choose to write.
She is not a licensed therapist, psychologist, massage therapist, or medical provider, and does not diagnose or treat any condition.

I understand Jane is completing her ERT practicum, that sessions are donation-based, and that any feedback I choose to write afterward is shared with Pat Jackman, identifying me by first name or initials only.

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.

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.

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.

Anything physical Jane should know about?

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.

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

How you're doing lately

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

I push through it
I get busy and productive
I go quiet and withdraw
I get short or irritable
I numb out — scrolling, food, drink
I move it out — gym, walking, running
I talk to someone
I overthink and analyze it
I don't notice until my body makes me

Anything you'd add to that?

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

Jaw, teeth, face
Neck and shoulders
Chest — tightness, shallow breath
Throat
Stomach or gut
Back or hips
Headaches
Sleep — falling or staying asleep
I don't really feel it in my body

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

I cry
I go numb or blank
I get angry
I laugh it off
I leave — I'm somewhere else
I hold it in until I'm alone
I explain it and analyze it
I don't know — it doesn't come up

When did you last cry?

And what did it take to get there — or how easily did it come?

Is there something you've been carrying that you're tired of carrying?

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.

Talk therapy
Somatic or trauma-informed work
Massage or bodywork
Breathwork or meditation
Energy work or sound healing
Plant medicine
Medication
Nothing yet — this is my first

What helped, and where did it stop helping?

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.

What was it like growing up in your household?

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?

The responsible one
The peacekeeper
The one who looked after everyone
The quiet or invisible one
The strong one
The funny one
The one who had to do well
None of these really

When you were hurt or scared as a child, who did you go to?

"No one" is a real answer.

This session

What are you hoping to reach or release? *

Is there anything you're nervous about going into this?

Is there anything you'd need from Jane to feel comfortable?

Pacing, particular words, being checked in with, silence, going slow at the start.

Anything about touch she should know?

Any area you don't want touched will not be touched. Sensitivities, injuries, and past experiences all belong here.

Anything else you want her to know before you walk in?

Your information

About your practitioner

Section 1 — Before we begin

Section 2 — Consent to touch

Section 3 — Your right to stop

Section 4 — Health confirmation

Section 5 — Disclaimer

The second part — where you are

How you're doing lately

Where you come from

This session

Electronic signature

Received 🌿