Client Participation Agreement & Bill of Rights

First Name *

Last Name *

Address

Street Address *

City

State

Country

Postal code

Phone *

Email *

Age

How did you hear about us? *

What would you like to transform? *

Have you ever been in therapy before? *

Yes

Have you ever been hypnotized before? *

Yes

Are you currently taking any medications? *

Yes (please state for what reasons below)

Reasons for medication

As I enter into this relationship, I agree to the following:

I am participating in hypnosis by my own choice because I want to be here.
I understand that I am not a patient, but a co-operator in my hypnosis experience.
I acknowledge the futility of blame for both me and others.
I understand my progress here involves how I care for myself physically, mentally, emotionally, and spiritually.
I understand that transformation is a process and that it can take time.

**By signing this form, I acknowledge that I will give a 24-hour notice in case I need to cancel or reschedule my appointment and that if I do not, then I will pay the full price of the session that I had scheduled.

Client Signature *

Clear

As your Hypnotherapist, I commit to you to utilize all of my skills to help you to reach your goals in the shortest time possible. You have my assurance of my full integrity, professionalism, confidentiality, and respect.

Contact Information: My name is Michelle Lynn and I can be reached by phone at (407) 606-5011 or by email at [email protected].

Notice: AS THE STATE OF FLORIDA HAS NOT ADOPTED EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTHERAPY, THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY. Hypnotherapy is a self-regulated profession, and its practitioners are not licensed by state governments. I am neither a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to a coordinated transfer to another practitioner. A client has a right to refuse hypnosis services at any time. A client has a right to be free of physical, verbal, or sexual abuse. A client has a right to know the expected duration of sessions and may assert any right without retaliation.

Hypnosis Law: I am not a licensed practitioner of the healing arts as defined by the Florida Hypnosis Statutes. I therefore only practice non-therapeutic hypnosis. If you wish to work with me using therapeutic hypnosis for a medical, mental health, or dental condition, then this requires a written referral from a qualified licensed practitioner. I will always operate within the scope of my credentials and within all federal, state, and local laws.

Certification: I am a member of the International Association of Interpersonal Hypnotherapists (IAIH) and have been certified by the Institute of Interpersonal Hypnotherapy which must be annually licensed with adherence to all applicable federal, state, county, and city regulations. IAIH certified schools are required to provide a minimum of 500 hours of state licensed training, of which I am certified. IAIH adheres to strict guidelines to ensure the attainment of core competencies and educational objectives. I will always operate within the scope of my credentials and within all federal, state, and local laws.

Ethics: I abide by the Code of Ethics of the International Association of Interpersonal Hypnotherapists (IAIH). For more information on the IAIH and its standards for the practice of ethical and professional Hypnotherapy, please visit https://InterpersonalHypnotherapy.com.

Other Services: Services other than my own may be available to you in the community. You may locate such providers through an internet search or by reaching out to the IAIH. As my client you have the right to refuse any aspect of hypnotherapy services or to completely terminate services at any time, or to choose another practitioner.

Fees: Sessions are approximately 2 hours. There is a discount for multiple sessions. Payment is due at the time of each session in the form of cash, credit card or via PayPal. Sessions paid in advance are non-refundable. You will be given a 14-day notice of any change in fees. I have a 24-hour cancellation policy and clients are charged for a full two-hour session if they do not call to cancel or reschedule in accord with this 24-hour notice.

Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you. As my client you have the right to complete and current information concerning any aspect of the professional/client relationship.

Insurance: I suggest you think of my services as something that you will pay for personally. That will both protect your privacy and help you value the work you are doing more. In general, most insurance companies do not cover hypnosis services, and I caution you not to expect them to do so.

My Approach: It is my goal to help you to achieve lasting results through the use of hypnosis, NLP, Parts Therapy, Regression, meditation, and other related self-help modalities. Through the power of your own mind, I will assist you in reaching your goals in a way that you and I both agree to be in your best interest and in a way that is in compliance with state and federal laws, as well as with the standards of the organizations to which I belong. I agree to use my experience to facilitate the changes as are mutually agreed to be in your best interest. I am professionally committed to mobilizing your inner resources in the shortest time possible.

By signing this agreement, you agree with the following declaration:

I am of legal age and in consideration of my acceptance as a participant in this seminar, hypnosis session, regression, training, or any other MichelleLynnHypnosis,LLC production. I for myself, my heirs, executors, administrators, and assignees, do hereby release and discharge MichelleLynnHypnosis,LLC from all claims of damages, copyright, demands, or actions whatsoever in any manner arising from or growing out of my participation. I understand recordings may be made with my permission and MichelleLynnHypnosis,LLC retains the copyright of these recordings.

Initials *

Today's Date *

Virtual hypnotherapy for Orlando, Central Florida and clients nationwide

[email protected] | (407) 606-5011

Virtual hypnotherapy for Orlando, Central Florida and clients nationwide

[email protected] | (407) 606-5011

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*Disclaimer: Results vary from person to person. Success with Hypnotherapy/Hypnosis depends on many variables, such as attitude, personal health and history, follow-through, adherence to the program, etc. Michelle Lynn Hypnosis does not diagnose, treat, nor prescribe for any medical or psychological disorders. If you suffer from a psychological or medical disorder, please consult a qualified physician or psychotherapist.