Client Information & Benefits Form

  • Confidential Client Intake Documentation

  • Welcome to The Empowered Living Hypnotic Program

    Congratulations on taking action toward your goals! I sincerely thank you for allowing me to be a part of your success story.

    During your sessions with Empowered Living Hypnosis, you will meet with Cindy Shuffield, MA, CPH, CPC.

    Sessions are scheduled as a 120-minute-block, though appointments can run between 75-120 minutes in length. Please set aside the entire 120-minute block plus give yourself some downtime after the session before stepping back into your daily routine when possible. I try to keep to a strict schedule, but occasionally we may run long. If we're running a little off schedule, please know that it's always for a good reason.

    Your Customized Program...

    My goal is to provide you with the most effective process in the most efficient use of your time.

    We’ll begin your process with a systematic series of sessions that include customization for your unique set of needs, continued reinforcement, and self-hypnosis training.

    Many clients reach their goals in the initially scheduled sessions, and most people (but not everyone) begin to experience benefits from the very first session. 

    Personal change is a process. Many clients elect to schedule follow-up sessions for reinforcement or continued coaching and support.

     

    ONLINE AGREEMENT...

    "By completing and submitting these forms online, and through payment for services, I am agreeing that all the responses are accurate to the best of my knowledge."

  • Client Information

    Please complete this form as best you can. I will utilize the information provided on these forms to tailor our sessions to your particular needs. So, your thorough efforts in completing these forms will help guide our process. Thank You!

  • TODAY'S DATE*
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  • Is the specific goal we've agreed to focus our effort toward to stop smoking?*
  • I live with a cigarette smoker.*
  • Others smoke in my work environment.*
  • Is the specific goal we've agreed to focus our effort toward to stop or reduce drinking alcohol?*
  • Is the specific goal we've agreed to focus our effort toward to lose weight?*
  • Is the specific goal we've agreed to focus our effort toward about sleep issues?*
  • Do you clench or grind your teeth during the day or night?*
  • Do you sometimes think or say negative unsupportive things to yourself about yourself and/or your goal?*
  • I'm facing stressful life events beyond my control at this time.*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you consider yourself a spiritual person?
  • Is it okay to Text Message you?
  • Follow-up by US Mail?

  • YOUR PART OF THE PROCESS...

    Hypnosis is a very powerful process that has helped millions of people make changes that you want to make in your life. However, hypnosis is not "mind control." For example, no one, not even the very best hypnotist, could MAKE you change your habits or behaviors.

    All hypnosis is self-hypnosis, and the responsibility of change is a shared agreement.

    Doctors don't guarantee that you will get well. Teachers can't guarantee that you will learn. Lawyers can't guarantee that you will "win" your case.

    What I can guarantee is the very best service using the latest in research, evidence-based strategies for change, and appropriate hypnotic, coaching and change techniques for your situation.

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  • Personal Investment & Goals

  • Your Investment in Yourself...


    Payments have been processed and/or scheduled as agreed upon during our Discovery Session.

    Your custom-designed process includes self-hypnosis training, and if appropriate, digital access to supplementary information or programs for strengthening the changes you create. “There is no change without change,” and this program is uniquely designed to help build new pathways in your habits, behaviors, and feelings.

    Sessions are non-transferable.  

  • Rescheduling and Cancellation Policy

    Appointment changes must be made at least 24 hours before the scheduled appointment or clients will either forfeit the session in the series OR pay a $50 rescheduling fee.

    Late arrivals of 30 minutes or more are treated as a missed appointment, thus non-refundable and not eligible for the $50 rescheduling option.

    Please make any necessary preparations to insure you are available and ready to participate in the sessions as scheduled. Due to the limited number of appointments available, the Rescheduling and Cancellation Policy must be enforced.

    Cindy Shuffield holds the right to make exceptions in a case-by-case bases should a client unexpectedly fall ill and be unable to participate in a session.

    Please reach out via Text or Phone Call (434) 443-6465 should you need to make a change to the scheduled sessions or will be arriving late.

  • Has anyone tried to hypnotize you?

  • The focus of our sessions is to get you from where you are to where you want to be, and the following information will help guide us.

    So, imagine that you have done the necessary change work and realized your goal, what are you now experiencing that's different because of the change you made?

    Please list 7 Specific Benefits & the Details of it that you are Looking Forward to Experiencing for having made the Changes you are Now Ready to Make.

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  • Brief History & Informed Consent

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    MEDICAL DISCLAIMER...

    “By agreeing to this, I understand that hypnosis and hypnotherapy are not meant to diagnose or treat any disease, but rather it is intended to provide information, education, and motivation that will promote feeling better, healing faster, and generally being more effective.

    It is designed to give me insight and tools into my innate healing potential and guide me into being more effective in helping myself.

    I also realize that hypnosis and hypnotherapy are not a substitute for conventional medicine, and I have been encouraged to seek the advice of a licensed health care provider should I choose to with regard to treating me for specific medical or psychological problems.

    If appropriate, I will receive a "Dear Health Care Provider" letter to share with my doctor to notify my use of hypnotism.

    I am stating that I have read this form and understand that, like the other healing arts, the practice of hypnosis and hypnotherapy, is not an exact science: Therefore, results are not guaranteed, nor are refunds given for services rendered.”

  • Please check if you have been treated for:
  • Do you give Empowered Living Hypnosis permission to contact your doctor(s) or therapist(s)??

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  • Client Bill of Rights

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    Cindy Shuffield is a Certified Professional Hypnotist with the International Certification Board of Clinical Hypnotherapists (ICBCH). She is also a Certified Professional Coach with the Institute for Professional Excellence in Coaching (iPEC).

    The Commonwealth of Virginia has not adopted any educational and training standards for the practice of hypnotism. This statement of credentials is for informational purposes only.

    Under Virginia law, a hypnotist may not provide a medical diagnosis or 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 coordinated transfer of services 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 treatment, and may assert any right without retaliation.

  • Your Right to File a Complaint...

    If you have any questions or complaints regarding any of our practitioners, please contact our office and speak directly to Mrs. Shuffield, at the address or telephone number listed on the Empowered Living Hypnosis website.

    If you have a complaint about our services or behavior that Mrs. Shuffield cannot resolve for you personally, you may contact the ICBCH at https://HypnotherapyBoard.com/.

    Other services than our own may be available to you in the community.

  • Insurance...

    We do not bill or make contact with insurance companies for services. Some insurance companies may reimburse you for services. Check with your insurance company or policy for additional details.

    We suggest you think of our services as something that you will pay for personally. That will both protect your privacy and help you value the work you are doing even more.

  • Theoretical Approach...

    The practitioners at Empowered Living Hypnosis utilize hypnotic techniques and instruction to help clients make changes both consciously and subconsciously. Techniques can include but are not limited to hypnosis, self-hypnosis instruction, relaxation training, coaching, visualization, instructional handouts, and digital access to audio & video supplements.

  • Assessment and Duration of Treatment...

    Hypnosis is a brief intervention process. It’s difficult to predict the number of sessions you will require to resolve your issue, though an ethical assessment is done in the initial call and a plan set from there. While hypnosis often produces instant results, lasting change is more often achieved over the course of several sessions and personal growth is not one size fits all.

    We’ll begin your process with a systematic series of sessions that include customization for your unique set of needs, continued reinforcement, and self-hypnosis training. Many clients reach their goals in the initially scheduled sessions, and most people (but not everyone) begin to experience benefits from the very first session. Hypnosis is a process.

  • Your Process Is Confidential...

    Client records and transactions with the practitioner are confidential, and may only be viewed by Empowered Living Hypnosis staff, unless release of these records is authorized in writing by the client, or otherwise provided by law. Sessions may be video recorded for insurance purposes and become part of your confidential record.  

  • "By completing and submitting these forms online and through payment for services, I am agreeing that all the responses on these four pages are accurate to the best of my knowledge."

  • Thank you for your efforts in completing this form!

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