Client COnsent Form

My Status and Scope of Practice

Hello, my name is Leigh Ann Lipscomb and I am both a Certified Resonance Repatterning practitioner and a Shamanic Energy Medicine practitioner. Both of these methods are gentle energy-based approaches to health and healing that can assist in bringing a body to its natural ability to heal. I do not diagnose or treat disease and I am not a physician. These sessions are not a substitute for diagnosis or treatment from a qualified health practitioner for illnesses, injuries, or other medical conditions. My services are not licensed by the State of California. My practice is guided by the Code of Ethics of the Energy Medicine Professional Association.

Basic Description of Resonance Repatterning

Resonance Repatterning is a system by which the subconscious patterns that contribute to a problem we are facing are identified by muscle-checking. The problem and the associated, underlying subconscious patterns are released with any of a number of modalities including, but not limited to, color therapy, visualizations, acupressure, cranial sacral, sound healing, movement, and many others. All sessions are unique for the client and the particular issues he or she is facing.

Basic Description of Shamanic Energy Medicine

Shamanic Energy Medicine involves upgrading the quality of the luminous energy field (we all have one) by removing imprints of trauma and disease. By doing this we create the conditions for health.

Description of a Session

During a session (the average is about 90 minutes), muscle-checking will be used along with client preference to determine whether Resonance Repatterning or Shamanic Energy Medicine is the best approach to be used for the client's issues. Shamanic Energy Healing, and some Resonance Repatterning sessions, include light physical touch. Resonance Repatterning sessions involve the identification of sub-conscious patterns related to a client's issues. Clients have many different responses to the sessions. Some feel relaxed and others feel nothing at all. Others describe sensations of moving energy, deep relaxation, feelings of being supported and nurtured, or visions of images and colors. Some clients experience an emotional release such as tears or laughter; some have what they consider to be a spiritual experience or they may develop insight into specific areas of their lives.


Recent research suggests that both modalities are effective for relaxation, stress reduction, and increasing one 's sense of vitality. Clients typically report feeling relaxed and often report an increased sense of well-being and peace. Many have reported positive experiences that have helped them better cope with illnesses, medical protocols for treatment of medical conditions and depression but I can make no specific claims regarding the results you may experience.

Training and Experience

I have the following credentials: 
  • Diploma from the Resonance Repatterning Institute of Chloe Faith Wordsworth
  • Certificate from the Shamanic Energy Medicine program of Alberto Villoldo at the Four Winds Light Body School
Confidentiality / Client Rights:

Your experiences during our session are confidential, and you have a right to view your files upon written request. Confidentiality is subject to the following exceptions:

1. You may instruct me to release information to other health care practitioners in writing.
2. I may release information if subpoenaed or otherwise legally obligated or reasonably allowed to do so (including circumstances where there is clear or immediate danger to yourself or another person).
3. Your confidential personal file is kept in a secure location and is retained for 2 years after you suspend services after which time all information will be destroyed in a proper manner.
4. Your confidentiality is always subject to the usual exclusions dictated by state and federal laws and regulations.


I have read and understand the above disclosure regarding the services offered by Leigh Ann Lipscomb. We have discussed the nature of the services to be provided including information that Resonance Repatterning and Shamanic Energy Medicine are holistic complementary and integrative energy based therapies that may at times be accomplished through the use of physical touch. I understand that she is not a licensed physician and that her services are not licensed by the state of California. I understand it is my responsibility to maintain a relationship for myself with a medical doctor or licensed therapist, if I so desire. I further understand that the above named is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies. I have read and understand the above disclosure regarding privacy policies and confidentiality, and that experiences during these sessions are confidential, but subject to the usual exceptions governed by laws of the State of California and other federal laws and regulations. I or my representative(s) agree to full release and hold harmless Leigh Ann Lipscomb from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). I have been informed that my Practitioner will neither diagnose nor prescribe for any condition that I might have nor does she make any specific claims regarding results from the sessions that I receive. My questions have been answered to my satisfaction regarding Leigh Ann Lipscomb's background, a session, and what I might expect from this session. I fully consent to use the services offered by Leigh Ann Lipscomb by e-signing below. By typing my name in the box, I indicate my signature.