Loading...

I, the undersigned, acknowledge that the energy work offered by Terah Pack, referred to as “Light Body Activation,” “Cosmic Consciousness,” “breathwork,” “emotional release work,” “Spinal Energetics,” or similar designations, is a modality that affects my energy system, consciousness, psyche, and physical body. I understand that while this practice has its roots in various traditions, it is not fully recognized or understood by Western medicine or psychology.


I recognize that this work is intended for individuals seeking personal growth and emotional well-being. I may experience a range of thoughts, feelings, and sensations during and after the session(s), which may be challenging or uncomfortable.


I understand that changes in my physical, mental, or emotional state may occur, and these responses are unpredictable. This work is not suitable for individuals with a history of mental instability or those experiencing active suicidal or homicidal thoughts. It is not a substitute for medical treatment or psychotherapy.


I acknowledge that Terah Pack and anyone working with me in these sessions are not licensed medical or mental health professionals, and I will not consider their communications as medical advice. I accept that results from the session(s) vary, and that I am responsible for my mental and physical fitness to participate.


I certify that I am 18 years of age or older, and I am free from any medical or psychological conditions that would preclude my participation. I will communicate any discomfort regarding physical touch during the session(s).


I voluntarily choose to participate in the session(s) and understand that I will not receive any refunds for services rendered or for pre-paid sessions not completed within one year of purchase.


I acknowledge that participation in these sessions, which may include energy work, breathwork, emotional release, and Spinal Energetics, carries inherent unpredictability. By attending a session, I release Terah Pack and anyone working with me from any and all liability for any circumstances arising from my participation.


I HAVE READ AND UNDERSTAND THIS AGREEMENT. 


Today's Date: May 25, 2026

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
What emotional blocks do you want to address?
Describe any physical symptoms or pain you experience (including location and intensity on a scale of 1-10)
What is currently your biggest source of conflict or stress in life?
What are three beliefs about yourself that may not be true?
How would you describe your childhood?
When do you feel most emotionally unregulated?
What triggers this? *
A. Food
B. Relationships
C.stress
D. Not having a regulation strategy / sports / relaxation routine
E.Emotional Trauma
F.Addictive behaviours
G. All of the above
H. Other:
New Option
When do you feel the most emotionally regulated, and why?
I let go of the expectation that this session will solve all of my problems. *
No
Yes
The emotional release process cannot take away my emotions. *
No
Yes
I understand the Neo Emotional Release cannot take my difficult emotions from me.*
No
Yes
I understand that the real life changing work is done at home.*
No
Yes
I am ready and willing to go through a deep emotional process.*
No
Yes
Change requires personal ownership of my emotional process. *
No
Yes
I am aware that emotions may intensify before they improve. *
No
Yes
I will reach out for support if needed. *
No
Yes
I understand that released emotions may trigger past patterns.*
No
Yes
I feel safe and comfortable with my emotional release-Guide*
No
Yes
I trust my body's intelligence in this process. *
No
Yes
I will provide feedback after the session for my Release Guide*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!