• Psychotherapy Consent Form

    This is a confidential record of your medical history and will be kept in this office. Thank you for your interest in Psychotherapy, counselling, hypnosis and the Holistic Healing Arts related to Mind Body Medicine. This is a growing brand of healthcare that is based on the principles of balancing and harmonizing the whole body. This is done through modalities including hypnosis, energy work, and life coaching. Everyone is unique, and each plan is tailored for each individual client. A holistic approach promotes prevention, positive change and well-being. The following questions are a way to get started. Please answer the following to the best of your ability. We can discuss further either by phone or with session work. Sign and click the submit button at the bottom. Thank you.
  • Format: (000) 000-0000.
  • Do you wear contact lenses?*
  • If hypnosis is performed, during hypnosis your eyes will be closed for about 45 minutes. If your contact lens will cause irritation, you may want to bring your lens holder and solution so you can remove them just before hypnosis

  • Are you hearing impaired?*
  • I will position you for optimal hearing or speak louder if needed. If you normally wear a hearing aid, please use it as you will have your eye closed and will not be able to lip-read during the session.

  • Your Goal:

  • What are your current thoughts/beliefs about your health?
  • I would like help with:
  • Pain Management:

    If you are seeking treatment for Pain Management, please answer the following questions.
  • Describe your discomfort
  • Is your pain or discomfort due to one of the following?
  • Describe the intensity of your discomfort from 0 (no pain) to 10 ((the most pain imaginable).
  • Describe the character of your discomfort.
  • Brief Medical History

  • Have you had a check-up or physical within the past year?
  • Are you under the care of a physician for any ongoing condition or illness?
  • If you are not seeking pain management, are you in any physical pain, either intermittent or constant?
  • Are you under the care of a mental health professional?
  • Have you been diagnosed with any of the following?
  • Previous Experience with Hypnosis/ Psychotherapy works

    If you have had any previous experience with hypnosis or meditation or psychotherapy works, answer the following questions.
  • Any previous experience with hypnosis/ psychotherapy?
  • How was it conducted?
  • CLIENT BILL OF RIGHTS, CODE OF ETHICS & CONSENT FORM

  • Hours are by appointment. CONTACT INFORMATION: My name is Dr Madelene Ong YS, MD, psychotherapist, clinically Certified Hypnotist and Mind Body Medicine Practitioner 16147. . I received additional certification of MasterPractitioner in NLP in 2016. I also have extensive additional training and certifications in alternative therapies. Please refer to my website or ask me in person for additional details. I am a licensed health care provider however I 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 coordinate transfer of services to another practitioner. A client has the 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. FEES & PAYMENT: Payment is due in full at the time of service by cash or debit card, or prior to service using Paypal. The fees for your particular issue or goal will be discussed with you prior to your first visit. You will be given a fee schedule and estimated number of visits at your first session. Fees are subject to periodic review and change. Your fee schedule will remain the same for at least 12 months. CANCELLATION POLICY: My time is my income and my hours are by appointment. Your time slot is reserved exclusively for you. Please arrive promptly to obtain your full session. A 24-hour cancellation notice is required, except in an emergency or inclement weather. If you must cancel or reschedule due to an emergency, please notify me as soon as possible. Thank you for your consideration. PREPAID SESSIONS: The above Cancellation Policy also applies to any programs with prepaid sessions. Except for emergencies or bad weather, 24-hour’s notice is required. Failure to keep your appointment or non-emergent short-notice cancellations may result in the forfeiture of a prepaid session. No refunds will be given for unused prepaid sessions. All prepaid sessions are non-transferrable and will expire after twelve months. 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 or a summary of my record about you. MINORS: Appointments for children under age 18 require written consent from the parent or guardian, who must accompany them at each visit. INSURANCE: I do not file insurance or any other third party claims. Insurance companies usually consider hypnosis as an alternative therapy and therefore do not cover it. MY APPROACH: I believe that individuals have the right to choose or practice alternative or complementary self-improvement services. Hypnosis is safe and non-invasive. The services I render are held out to the public as a form of motivational coaching and education, combined with instruction in self-hypnosis. I do not represent any of my services as any form of health care, psychotherapy or counseling. Hypnosis is not meant to be a substitute for psychological or professional counseling. If you have an ongoing mental health problem, please consult a licensed professional. I use hypnosis to motivate clients, to eliminate negative or unwanted habits, facilitate the learning process, improve memory and concentration, develop self-confidence, eliminate stage fright and performance anxiety, sleep better, reduce/manage stress, focus on positive thoughts and desired outcomes, and for other social, educational and cultural endeavors. In general, I help people cope with the normal problems of everyday living by utilizing various techniques of hypnosis, progressive relaxation and energy work. Most hypnosis is of a non-medical nature. Despite research to the contrary, by law I may make no health benefit claims for my services. However, hypnosis does reduce stress, which is a beneficial adjunct for many medical and mental health disorders. Relaxation techniques can be learned which can reduce discomfort and improve certain health issues. I believe that thoughts and attitudes can influence how we feel and that hypnosis can help you change habits, focus on the positive, and visualize a state of wellness. CLINICAL HYPNOSIS: NO GUARANTEE AND REFUND POLICY: No guarantees as to the effectiveness of hypnosis for your particular problem are made or implied, as it is impossible to guarantee human behavior or compliance. Therefore, no refunds for services are given. Hypnosis is not a quick fix or magic pill. A hypnotist is considered a guide or facilitator. You assume equal responsibility by making a commitment and allowing yourself to be guided into a state of hypnosis. No one can make you do something against your true will. I HAVE READ THIS CLIENT BILL OF RIGHTS AND I FULLY UNDERSTAND WHAT I HAVE READ. I acknowledge receipt of a copy of this statement for future reference.


     

    CODE OF ETHICS

    The Bristish Society of Clinical Hypnotherapy(“BSCH”) provides standards and guidance for the practice of hypnotherapy, and regulates the conduct of its members in their practice.  All registrants are required to comply with the BSCH Code of Ethics by signing the declaration below:
    As a Hypnotist holding a Certification from the British Council of Hypnotist Examiners, I commit myself to conduct my professional relationships in accordance with the Code of Ethics and subscribe to the following statements:

    1.    I regard as my primary obligation the welfare of my client, whether individual or group.
    2.    I will comply with the requirements of the law in the jurisdiction where I practice, including requirements with regard to dealings with clients in relation to race, religion, age, and gender status.
    3.    I will offer services only within my scope of practice and boundaries of competence and the recognized knowledge and competences of the profession of hypnotherapy.
    4.    I will not claim to diagnose, prescribe treatment for, or treat any mental or physical illness unless I possess qualifications additional to hypnotherapy certification, which legally entitle me to do so in the jurisdiction where I practice.
    5.    I will not use any licensed or restricted title to which I am not legally entitled in the jurisdiction where I practice.
    6.    I will advise a client whose requirements are outside my boundaries of competence to seek an appropriate alternative service.
    7.    I will advise any client presenting symptoms of physical illness, including pain, to seek the advice of a medical practitioner if this has not already been obtained.
    8.    I will not guarantee cures for any condition or make misleading claims or statements as to the outcome of the services I offer.
    9.    I will make clear to the client, prior to the provision of services, the terms, conditions and charges for my services.
    10.    I will maintain confidentiality of information obtained during the course of providing my services, within the legal limits of reporting requirements in the jurisdiction where I practice.  I will disclose any such limits of confidentiality to my clients prior to providing services.  I will ensure that the client’s anonymity and privacy is safeguarded in the publication of any clinical material.
    11.    I will obtain the written consent of a parent or guardian before providing services to a minor.
    12.    I will not engage in intimate social contact with a client until a period of at least two years from the final session with that client.
    13.    I will undertake continuing professional development and education in accordance with the requirements of BSCH as updated from time to time.
    14.    I accept responsibility to help protect the community against unethical practice by any individuals engaged in providing hypnotherapy services e.g. by reporting professional misconduct to the proper bodies or authorities.
    15.    I treat with respect the findings, views and actions of professional colleagues and use appropriate channels to express my opinions on these matters.
    16.    I will conduct myself in a manner consistent with upholding the good reputation of the profession of hypnotherapy.
    17.    I will distinguish clearly in public between my statements and actions as an individual and as a representative of an organization.

  • Date*
     - -
  • Appointment*
  • I sincerely want you to succeed and pledge my efforts to help you to the best of my ability.

    ~ Dr Madelene Ong, CCHt

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