Safety Questionnaire and Disclaimer

The class teaches you a powerful form of psychotherapy, and even though the class isn’t psychotherapy, the work you will be learning to do can access deep places inside you. For some people, this can bring up emotional reactions that may be hard to deal with. IFS is a very safe and respectful form of inner work, but for a few people this class may not be safe.

To help determine whether this class is safe for you, please fill out the questionnaire below and sign the accompanying disclaimer. Please mail them to

Safety Disclaimer
140 Marina Vista Ave.
Larkspur, CA 94939

Or fax them to 415-924-5256. (I must be there to receive the fax, so if it doesn’t go through, leave me a message at that number and we’ll arrange that.)

If you would like to discuss whether the class is safe for you, feel free to call Jay at 415-339-8060 or Bonnie at 415-924-5200.

Questionnaire

Name:

Phone numbers:

What psychological issues are you facing now or wanting to work on?

How much and how frequently do you currently use drugs and alcohol?

Do you have any history of emotional instability? Please explain.

Is there any danger that accessing pain or childhood memories could be destabilizing for you?

Have you been hospitalized for psychiatric reasons or treated with psychiatric drugs? Are you currently on any psychiatric drugs?

Are you currently in psychotherapy? For how long?

If you were in emotional difficulty or felt like you were falling apart, where would you turn?

Disclaimer

I understand that the IFS Classes are not psychotherapy. Even though they teach a psychotherapy method, they are intended to teach me skills I can use for my personal growth. They may involve accessing sensitive psychological material, and I declare that I have the psychological stability to handle whatever may come up. I am responsible for my participation in the class and any psychological work that I choose to do, and I will not hold Jay Earley or Bonnie Weiss responsible for any pain or damages that may occur.

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Name  

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Signature                                                                     Date