The undersigned hereby declares that they have understood and agreed
with the following, first about the regression process, and secondly about
providing data for research:
A first cause regression treatment by a Regression Counselor/Practitioner of my choice from those participating in the study. The Regression Counselor/Practitioner is in accordance with the professional profile and practice rules of the EARTh Association for Regression Therapy, and the local and medical laws of the country the regression process takes place in.
With the signing of this agreement, the undersigned client declares:
I am fully informed about the research and the regression process by
my regression counselor.
It is my own responsibility to consult with my (family) doctor and /
or medical specialist about undergoing this therapeutic treatment and any
possible modification, reduction or stopping of medication.
I understand that regression is not a
substitution for regular psychological or medical treatment and that I am
responsible for calling in appropriate regular (psychological or medical)
treatment if there is reason to do so or receive advice to do so from the
treating therapist. I do not have to wait for permission from the
regression counselor/practitioner.
I agree with the regression process and realize that the result of the
research also depends on my cooperation to fill in the forms, reports and
participating to the sessions.
I have been informed that this therapeutic treatment can have an
effect on my symptoms and physical and emotional functioning and that I will
always inform the counselor.
I have learned about the possibilities of complaint handling through
the regression counselor / EARTh website: https://www.earth-association.org/ - to be filled in later.
I am aware of the confidentiality of the information provided. I am
entitled to view the information held about me and my process by the regression
counselor/practitioner and I must give permission for sharing personal
information with third parties (general practitioner, specialist), unless
another statutory provision applies, such as the duty to report child or parent
abuse. I am aware of the privacy policy, which can be found on the EARTh's
website.
After reading the above and based on all the information received, I
have come to a well-considered decision to want to undergo regression process
with this regression counselor/practitioner.
Furthermore, I am aware that and agree with that my problem with
primary and/or secondary dysmenorrhea (menstrual pain) is specifically the
focus of the process.
I am aware that I am not suitable for this research, if I currently
use contraception or hormonal spirals; and I will be excluded from the research
if I start using contraception or hormonal spirals during the research process.
Also, I am aware about and agree with the sharing of anonymized data
of this treatment and the results of the research with the Research Committee
of EARTh Association. I also agree to analysis and publication of my anonymized
data, again, no identifying details will be revealed, and anonymity is
guaranteed.
The purpose of this research is to explore if regression process has
any influence on reducing the pain and changing the quality of life in a wider
group. I know that I am always entitled to view this data. Also, If I decide to
withdraw my cooperation, I can request that my data is destroyed, so that it
will no longer be part of the research.
I will provide the regression counselor with doctor's
reports form before the regression if I can. If I am not available to provide a
gynecologist’s diagnose, it is my personal responsibility to provide correct
data to the research; and I will fill the forms after one menstruation and
after 6 menstruations after Regression sessions.