Informed Consent & Acknowledgment

Duyukta Connective
Integrative Body Coaching / ISST Body Coaching

Practitioner: Rebecca Stacey
Client Name: ___________________
Date: ______

Nature of the Work

I understand that sessions offered through Duyukta Connective incorporate Integrative Systemic Supportive Touch (ISST) Body Coaching, soma-based support, and presence-based body work.

This work is educational, supportive, and wellness-oriented in nature. It is designed to work with the body’s natural capacity for regulation and organization through gentle touch, awareness, and nervous-system attunement.

I understand that this work:

• is not psychotherapy, counseling, or medical treatment

• does not provide diagnosis, treatment, or cure of any condition

• does not replace medical, psychological, or psychiatric care

Scope & Limitations

I acknowledge that:

• Results are individual and cannot be guaranteed

• This work does not involve analysis, advice, or prescriptive treatment plans

• Emotional, physical, or sensory experiences may arise—or may not

• I am free to pause, adjust, or stop a session at any time

I understand that my participation is voluntary and that I may withdraw consent at any point without penalty.

Touch & Boundaries

I understand that sessions may involve gentle, non-invasive touch used for supportive, regulatory purposes only.

Touch is:

• always optional

• guided by ongoing consent

• non-sexual and non-manipulative

I agree to communicate any discomfort, concerns, or preferences at any time during the session.

Client Responsibility

I agree to:

• inform the practitioner of relevant health conditions or limitations that may impact sessions

• continue appropriate care with licensed medical or mental health professionals as needed

• take responsibility for my own well-being before, during, and after sessions

Confidentiality

All personal information shared is held in confidence and will not be released without my written permission, except where required by law.

Acknowledgment & Consent

By signing below, I acknowledge that:

• I have read and understand this consent form

• My questions, if any, have been answered

• I consent to receive Integrative Body Coaching / ISST sessions through Duyukta Connective

• I understand the nature, scope, and limits of this work

Client Signature: _______________________________
Date: ___________________

☐ I have read and agree to the Informed Consent for Integrative Body Coaching / ISST services through Duyukta Connective.