REGISTRATION FORM

Jelena Hohlun is a NEITHER TRAINED MENTAL HEALTH PROVIDERS NOR MEDICAL PRACTITIONERS.  THE SERVICES ARE NOT INTENDED TO REPLACE MEDICAL TREATMENT.

Provider (Jelena Hohlun) does not offer the services or treatment of a licensed physician, clinical psychologist or psychiatrist. Provider is not licensed to practice psychology, and Provider does not claim to offer any psychological benefits, or psychometrist (or any form of psychometrics) or psychometry services.

Provider disclaims all statements, representations, warranties, agreements or promises regarding the use or benefits of the Services, whether made by Provider, its clients, employees, agents, or contractors. Participating in the Services does not guarantee success, and Provider makes no representation or guarantee through Client’s participation in the Services. All information on the Provider website or included in statements, testimonials or materials made or distributed by or on behalf of Provider are for informational purposes only, and are not intended to be relied on by Client or to constitute a representation of the effects or benefits of the Services.

 

ASSUMPTION OF RISK, RELEASE OF LIABILITY, AND AGREEMENT TO ARBITRATE

PLEASE READ THE FOLLOWING CAREFULLY. BY SIGNING BELOW, YOU ARE GIVING UP CERTAIN LEGAL RIGHTS.

By my signature below, as the “Client” (and if applicable “Guardian”), I further represent that I have read and understood and agree to the following:

I freely and voluntarily choose to participate in the Services provided by Provider. My participation may include unknown negative reactions. I accept any and all risks for any adverse reactions that I may have. I understand that participants with certain health conditions such as epilepsy and psychosis are not recommended to participate in the Services. I represent to Provider that I have no such health conditions that would prevent me from safely participating in the Services.

I HEREBY ASSUME ALL SUCH RISKS associated with the Services, know or unknown, including without limitation injury, illness, death, and/or other adverse reactions. I am aware of such risks associated with the Services, including my own physical condition and the actions or conduct of others that I may come into contact with after participating in the Services. I understand that by participating in the Services, I may experience emotional personal memories.

ASSUMING ALL SUCH RISKS, I HEREBY RELEASE, WAIVE ANY AND ALL CLAIMS AGAINST, WILL NOT SUE AND WILL HOLD HARMLESS, Provider from all actions, omissions, causes of action, suits, debts, damages, losses, judgments, injuries, liabilities, and claims and demands whatsoever, in law or in equity (collectively, “Claims”), including without limitation.

Personal injury and death, emotional distress, indirect damages, consequential damages or exemplary damages, even though such Claims may be caused by or result from the negligence or carelessness of such released parties.

I agree that this waiver and release binds me and my heirs, distributees, guardians, legal representatives, successors and assigns. Further, I agree to indemnify, protect, defend and hold harmless Provider, its owners, members, managers, officers, employees, agents and representatives, from and against all Claims arising from or in connection to my involvement or participation in the Services offered by Provider.

Jelena Hohlun reserves the right to end the client relationship at any time if reason has arisen to do so with a refund of any further sessions given excluding existing services received.

 

CONFIDENTIALITY

In accordance with legal and professional ethical standards, Jelena Hohlun will maintain confidentiality about the issues that are discussed in therapy and will not disclose the information I provide her to a third party, unless I give my prior consent.

Even so, there are a few exceptions to the confidentiality laws and standards, as follows:

▪        If Jelena Hohlun believes that I am or someone else is in clear and imminent danger of harm, she will be obligated to inform the proper authorities in order to help prevent the harm from occurring.

▪        If I am under the age of 18 and report being abused, Jelena Hohlun is required to notify proper authorities. If I am over 18 and report direct knowledge of abuse of a minor or vulnerable population, Jelena Hohlun may be required to report such abuse to authorities.

▪        A court can order a therapist to disclose information about a client.

 

TIME

Sessions are between 90 – 120 minutes. If time permits and we run over I will still be charged at the set fee, however it might transpire that another session is needed to be booked in. Usually, most sessions are ample time for the hypnotherapy process to conclude.

A Zoom link will be sent for the agreed time of the hypnotherapy session.

 

PROFESSIONAL FEES

A single session is charged at £ 205. Any further sessions would be charged at the same set rate. In accompaniment to a session, this charge includes the time of the initial consultation and follow up correspondence after the session on the days listed below.

Payment has to be transferred ahead of the session via the link below.

Once payment has been made, there are no refunds and signing this contract means acceptance that these services are with a no refund policy as Jelena Hohlun has to prepare for each session outside of the hours of service.

 

NO SHOWS/LATE CANCELLATIONS

I understand that I will be on time and punctual with my sessions. If I need to change or cancel my appointment, I will contact Jelena Hohlun by email or telephone 48 hours prior to my scheduled appointment. Failure to provide 48-hour cancellation notice will result in the full fee being charged for the session.

 

CONTACTING ME AND ABSENCES

Jelena Hohlun can be contacted on: jelenahtherapy@gmail.com / +4479 1235 1686       

Jelena Hohlun will contact me by email on the following specific days after my session to follow up on my progress. These are days 4, 7, 10, 14, 21 and 28 and the follow up will be kept brief. It’s best practice to wait until the full 28 days for my final review and then I may decide whether a further session(s) is needed. Every client is different and individuals can experience change immediately and/or progressively.

I will refrain from contacting Jelena Hohlun outside of these follow ups as any further questions can be discussed in the next scheduled follow up. If I have a concern and would prefer a call to discuss the matter rather than by email, I will notify Jelena Hohlun in advance of the scheduled day so she can arrange a convenient time to call me instead. Any additional contact over and above the scheduled times will have to be charged for (pro-rated on the full session fee) as any other professional service.

Jelena Hohlun will make every attempt to inform me in advance of planned absences or rescheduling.

 

PRIVACY STATEMENT

By submitting this registration form I consent to the processing of my personal information solely for the purpose of this treatment and being contacted by correspondence by Jelena Hohlun in relation to this treatment. My personal details will be treated with the greatest care and confidentiality and will be kept under secure encryption.

Should I not be able to wait until our scheduled catch ups, within reason, please note Jelena Hohlun is not always immediately available by email or phone. If you contact her and, for a number of unseen reasons, I do not hear from her or she is not unable to reach me, and I feel I cannot wait for a return email or call, or if I feel unable to keep myself safe, 1) I will contact my local Community Mental Health Service or GP; 2) go to my local  Hospital Emergency Room; 3) call emergency services for urgent assistance in my country.

 

DISCLAIMER & DISCLOSURE REGARDING SERVICES

People with Epilepsy or any person diagnosed as having a psychotic illness should not enter hypnosis. Jelena Hohlun accepts no responsibility whatsoever. Under no circumstances including but not limited to negligence shall Jelena Hohlun be liable for any special or consequential damages in any way whatsoever now or in the future that result from the use of or the inability to use hypnosis, advanced hypnotic techniques, hypnotherapy, or any other therapies. The information, techniques, methods and recommendations by Jelena Hohlun are not intended to substitute for the diagnosis and a care of a qualified doctor nor to encourage the treatment of illness by persons not recognisably qualified. If you use hypnosis and are under medical care for any condition, do not make any adjustments to any prescribed medication without the approval of your doctor. If in any doubt, you should seek medical advice.

Jelena Hohlun has taken due care and attention with the information provided at this session and information is given in good faith. The information given is not intended to constitute medical advice. Always consult your GP before changing medications and evaluating treatment alternatives.

Jelena Hohlun does not accept responsibility for any loss, damage or expense resulting from the use of information provided. You agree to indemnify and hold us harmless by signing and agreeing to these conditions.

The information I have given here is to the best of my knowledge, full and correct. I undertake hypnotherapy on the understanding that it is a collaborative process, and that progress depends in part upon my own motivation and participation.

I accept that all appointments not cancelled within 48 hours will be charged in full.

By my signature below, as the “Client” (and if applicable “Guardian”), I represent that I have read and understood and agree to the information above.

By my signature below, as the “Client” (or if applicable “Guardian”), I accept the foregoing disclosure, disclaimer, assumption of risk and waiver, and I represent and warrant for Provider’s reliance, and agree, as material consideration without which Provider would not provide the Services, that:

(1)I HAVE CAREFULLY AND COMPLETELY READ AND AGREED TO ALL OF THE FOREGOING;

(2) all of my questions have been answered to my full satisfaction;

(3) I am not relying on any statement, representation or warranty, agreement or promise by or on behalf of Provider that is not expressly set forth in writing signed by Provider;

(4) I am aware that this is an assumption of risk, release of liability and agreement to arbitrate and that I am giving up legal rights; and

(5) I sign below of my own free will

 

IF CLIENT IS UNDER 18, THE PARENT (OR GUARDIAN, IF ANY) MUST SIGN BELOW: I am the parent or legal guardian of the above Client and he/she has my permission to participate in the Services with Provider. I have read and agree to the provisions stated above for myself and Client. I agree to indemnify, protect, defend and hold harmless Provider, its owners, members, managers, officers, employees, agents and representatives, of all liabilities, claims, losses, damage or injury to person or property which may occur or be incident to Client’s involvement or participation in the Services offered by Provider.

 Sessions are non-refundable once paid.