Informed Consent for Work with

LEA Systems and/or Light Stimulation

Although the LEA systems and light stimulation devices used here are generally safe, I understand the following information about potential hazards that may exist and that no claims about guarantees of effectiveness are made. Neither LEA systems nor the light stimulation instruments used in this office are recognized as medical devices for therapeutic purposes, and all participation with them is strictly voluntary and experimental. Although some research findings are known, there is presently not enough for either to be recognized as standard treatment.

___Yes ___No  Do you have cancer?

___Yes ___No  Do you have a pacemaker?

___Yes ___No  Do you have a history of photosensitive seizures?

___Yes ___No  Are you taking medications that are known to have photosensitive side effects? If so, check with your physician to determine if these side effects are significant enough to recommend avoiding low brightness light stimulation.

___Yes ___No  Are you having suicidal thoughts, or are you deeply depressed?

___Yes ___No  Do you feel prone to violence or homicide?

___Yes ___No  Do you have any other medical conditions that might be important to disclose here? If so, what?___________________________________



  The spiritual healing process sometimes involves provoking discomfort before relief is achieved.

  Delayed emotional and physical reactions from use of the LEA systems and/or exposure to light stimulation may occur.

  Although movement and/or release of energetic patterns or blocks in the human subtle energy fields may stimulate physiological and/or emotional benefits, no claims or guarantees are made for any physiological or emotional enhancement.


I understand and consent to participate in individual work with the LEA systems and/or light stimulation instruments, according to my preference.

Name (Please print): _________________________________

Signature: _____________________________________   Date: ______________