Disclosure Form and Agreement

Effective date: 09.24.24

As part of my work with Vicki Dau, I will learn about something called Emotional Freedom Techniques (EFT), which is a type of energy release technique. EFT is a relatively new approach to stress relief and the extent of its effectiveness, as well as its risks and benefits, are not fully known. The prevailing idea is that EFT uses the ancient Chinese meridian system to help alleviate stresses by balancing the energy system with a gentle tapping procedure. The procedure involves acupressure (tapping with my fingertips) on acupuncture points (called acupoints) on the face, upper body and hands with the goal of stimulating designated meridian end points on the face and body. While many people experience benefits with EFT, others do not. There is no scientific explanation regarding why EFT works for some people and does not work for others.

Vicki Dau is not a licensed psychiatrist, psychologist, social worker, or mental health professional. She is not licensed or trained to diagnose any form of mental illness, and she is also not licensed to prescribe or recommend any medication. I understand that I will not be receiving any form of mental health counseling with Vicki Dau.

By agreeing to the terms of  this document, I acknowledge that EFT is experimental, and, as part of my coaching sessions with Vicki Dau, I agree to assume and accept full responsibility for any and all risks that may be associated with EFT. I further understand and agree that the information presented in my sessions is for my personal use only and not for application to others.

I understand that through the use of EFT, unpleasant emotional or physical sensations or unresolved memories may surface, and I may experience some emotional distress related to prior life experiences. Emotions may continue to arise after the session. I understand that I am encouraged to discuss such emotions with an appropriate health care provider such as a licensed psychologist, psychiatrist, social worker, or mental health counselor.

In addition, I understand that by using EFT, it is possible that previously vivid or traumatic memories may fade. This could adversely impact my ability to provide detailed legal testimony regarding a traumatic incident.

I understand that since Vicki Dau is not a licensed psychologist, psychiatrist, social worker or mental health counselor, she may legally be subpoenaed to testify in a legal action in which I am involved and forced to give testimony regarding information learned during my involvement with Vicki Dau. While Vicki Dau promises to keep all information 100% confidential to the fullest extent of the law, I understand that I assume the risk of her being subpoenaed in a legal action and being forced to reveal personal information about me that would otherwise be confidential.

The information presented during the coaching sessions, including but not limited to information about EFT, is not intended to diagnose, treat, cure, or prevent any disease, illness, addiction, or other psychological, mood, impulse control, emotional, behavioral, or mental health disorder. EFT is not a substitute for professional medical, psychological, psychiatric or other mental health treatment. I understand that Vicki Dau does not recommend I stop seeing any of my health care professionals or using prescribed medicine without consulting with the appropriate health care professional.

Any stories or testimonials presented during my sessions do not constitute a warranty, guarantee, or prediction regarding my results from using EFT. I understand that Vicki Dau make no warranty, guarantee, or prediction regarding my individual results. I further understand that Vicki Dau strongly advises that I seek professional medical advice as appropriate before making any health decisions.

*If you abruptly end the session, and Vicki cannot get a hold of you, she will call your emergency contact to check on you.

I represent that I am an adult under the laws of the State of my residence and have the right to enter into this Agreement.

I acknowledge that Vicki Dau has given me the opportunity to ask questions regarding any aspect of this Agreement. By agreeing to the terms here, I acknowledge that I have carefully and completely read, and fully understand, all aspects of this Disclosure Form and Agreement and that I agree to all of the terms and conditions stated herein. This Agreement shall be binding upon me and my heirs and legal representatives.

Contact Vicki

If you have any questions, concerns or complaints about this Disclosure Agreement please contact us:

• By email: [email protected]
• By phone number: 630.745.8281
• By mail:
  TeamDau
  P.O. Box 87257
  Carol Stream, IL 60188