Please print your name in the first space, then below, sign, print, date and initial the last three statements, to indicate that you understand what you have read.
I, , agree to engage in the process on non-
therapeutic hypnosis. I understand that I will have all choices at all times and can start and end the process at anytime, even during my session. The services I am agreeing to are held out to the public as non-therapeutic hypnotism, defined as the learning of self-hypnosis to induce positive thinking, create commitment to change and to learn the techniques of self-hypnosis to produce self-control over physical experiences and emotional awareness, hypnotism has not been represented as any form of health care or psychotherapy, and I may make no health benefit claims for my services.
I agree to continue medication as prescribed by my attending physicians and understand that hypnotherapy is not a substitute for medical care. I understand a hypnotist neither diagnosis nor treats any medical or mental health condition, instead offering tools of self-discovery and awareness to compliment any medical treatment prescribed by a physician. If any medical symptoms progress or become acute I agree to seek medical attention from a licensed healthcare provider. In the event of a medical emergency or if I feel suicidal, I will call 911 or other emergency help. I understand that the methods of hypnosis include relaxation, breath work, creative visualization, positive affirmation, self-awareness development and other techniques and may produce physical and emotional responses. I agree to inform my hypnotist of any adverse feelings or experiences related to this process, at the time of my awareness of them. I have been informed as to the limits of hypnosis effectiveness and offered referral to other providers of alternative approaches to problem solving. I am over age 18, and consent to hypnosis services offered by Cathy Boone-Black