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Please feel free to email this information or print it out and bring them with you to the first session. Disclosure and Consent Form for Hypnosis/HypnotherapyNOTE: Hypnotist/Hypnotherapist/Practitioner are used interchangeably in the following document.
I, ____________________________ have been advised by Scott Sandland, C.Ht. the scope of hypnosis/hypnotherapy practice and I give my full consent to receiving hypnosis/hypnotherapy sessions Scott Sandland, C.Ht. I understand that results vary and that the above name practitioner may not guarantee results. Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Hypnotist/Hypnotherapist does not treat, prescribe for or diagnose any condition. I understand that the practitioner is a facilitator of hypnosis or hypnotherapy and is not practicing any other profession that requires a license under the laws of the State of California. I am aware and understand that in some cases it may be necessary for the practitioner to respectfully touch my shoulder(s), hand, wrist, or forehead in order to assist me in relaxation. I give the practitioner permission and consent to do so in order to help me establish a beneficial state of hypnosis. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability. I have accurately provided background information as requested by the hypnotist/hypnotherapist. I understand that confidentially regarding my sessions will be honored between Scott Sandland and me. This same confidentially is respected when working with minors under the age of eighteen.
Signature of Client ____________________________________________________________________________ Printed name of Parent or Guardian (if under 18) _______________________________________________________________ Signature of Parent or Guardian _________________________________________________________________ Date _______________________________________________
Disclosure Statement
CONFIDENTIALITY Matters regarding your sessions will be kept confidential except in the following circumstances: You grant me specific permission to release information to a specific individual or agency; child abuse; you are an imminent danger to self or others; or in the case of the subpoena of records. Any information shared is kept confidential. From time to time, I also consult with other colleagues, but in this circumstance, clients are not identified by name. Your signature below constitutes you giving permission for such consultations. FEES AND PAYMENTS The charge for Hypnotherapy is $175 an hour. Payment is due at the conclusion of each session. It is your responsibility to obtain information about your insurance coverage and to provide me with insurance forms. CANCELLATIONS Since I have reserved our appointment time for you, it is my policy to charge for cancellations received less than 24 hours notice unless we are able to reschedule the appointment within the same week. Insurance companies generally do not reimburse for failed appointments. REPORTS AND PHONE CALLS There is no charge for brief calls. Calls lasting longer than 20 minutes will be charged to the client on a prorated basis. Reports requested by insurance companies, physicians, etc. will not be released without your permission.
Client Name: _____________________________________________________________________ Client or Guardian Signature: ________________________________________________________ Client Address: ___________________________________________________________________ Home Phone: ______________________________ Work Phone: _____________________________ Mobile Phone: _____________________________ Emergency Contact: ____________________________ Phone: ________________________________ Client Assessment FormName: _________________________________ Phone: ______________________________ Today’s Date: _____________
Presenting Issue: ___________________________________________________________________________________________ _________________________________________________________________________________________________________
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When and under what circumstances did your issue begin? ___________________________________________________________ _________________________________________________________________________________________________________
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How has this affected your life? _________________________________________________________________________________ _________________________________________________________________________________________________________
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Has it ever been different? ____________________________________________________________________________________ _________________________________________________________________________________________________________
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What specifically about your issue is leading you to seek help? ________________________________________________________ _________________________________________________________________________________________________________
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Are you on any medication or have you ever been diagnosed with a mental illness? _________________________________________________________________________________________________________
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Please provide the name(s) and contact information of your doctor(s) or therapist(s): ________________________________________ _________________________________________________________________________________________________________
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What other kinds of therapies have you tried? _____________________________________________________________________ _________________________________________________________________________________________________________
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What life-style or attitude changes have been partially successful? ______________________________________________________ _________________________________________________________________________________________________________
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Do you associate any of these emotions with your issue?
Anger Anxiety Boredom Glamour Embarrassment Masculinity Frustration Depression Loneliness Happiness Loss Grief Femininity Shame Fear Abandonment Romance Relaxation Sadness Satisfaction
Other Emotions: ______________________________________________________________________________________
Goals for Therapy: What is your 1 month goal regarding this issue(s)? _________________________________________________________________ _________________________________________________________________________________________________________
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What is your 6 month goal regarding this issue(s)? _________________________________________________________________ _________________________________________________________________________________________________________
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What is your 1 year goal regarding this issue(s)? _________________________________________________________________ _________________________________________________________________________________________________________
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What is your 5 year goal regarding this issue(s)? _________________________________________________________________ _________________________________________________________________________________________________________
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Additional Comments: _______________________________________________________________________________________ _________________________________________________________________________________________________________
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Therapist’s Signature _________________________________________________ Date ____________________
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