Healing Way Hypnosis Service Agreement

 

Client Information and Release Form

The following information is intended to fulfill the requirements regarding hypnotherapists and their services as required by California Senate Bill #SB577, passed in September 2002. If you have any questions or need additional information, please let me know.

 

1. Please note that I, Hilary Jacobson, ACHE Certified Clinical Hypnotherapist, am not a licensed physician. I am not qualified to prescribe medication, diagnose medical or psychological conditions or treat mental disorders.

2. I am a certified clinical hypnotherapist through the American Council of Hypnotherapists, am certified as a Medical Specialist, and have ongoing education in Ericksonian Hypnotherapy, Neuro-linguistic Programming, Imagery and other modalities. I have been certified as a Swiss Holistic Breastfeeding Consultant, (CH.HU.SI), with specific education on birth and breastfeeding, and special studies in nutrition and herbs, hormonal syndromes and related medical issues. While this training can help me better understand your situation and create hypnotherapy sessions especially for you, I am not a licensed physician and do not give medical advice.

3. Confidentiality: our conversations, sessions, emails and any notes taken are protected. At our first meeting, we can discuss the legal and ethical limits of confidentiality.

4. The treatment with hypnotherapy and any alternative modalities used, are alternative or complementary. Services that I provide include relaxation techniques, heart-centered self-hypnosis training, Integrative NLP, and hypnosis for the purposes of stress release and pain management. I specialize in women’s issues such as PMS and PMDD, migraine, birth preparation, sadness and grief around childbirth and breastfeeding, and other concerns of the mother and family  

5. It is my goal to provide to my clients a supportive, safe, non-judgmental and nurturing environment. Based upon the theory that all hypnosis is self-hypnosis, I am committed to guide clients toward reaching their own insights, goals, healing, and self-transformation.

6. I do not guarantee outcomes from these sessions. Your attendance is based on your choice to address your particular issues using hypnotherapy and related modalities. There is no promise as to results.

 

I have read the above and I understand.

Please sign below with your legally binding electronic signiture, click on the date icon to mark the date.