By signing this form I, (the Client), hereby release Maria Motea (The Therapist) from any liability or claims that could be made against her concerning my mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form.
Scope of Practice
I understand that Maria Motea is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnosis should not be considered a replacement for the advice and/ or services, of a psychiatrist, psychologist, psychotherapist, or doctor. Individuals diagnosed with epilepsy or a psychotic illness should not participate in hypnosis. If uncertain whether hypnosis is right for you, please consult your physician.
Personal Details
The information I have given here is to the best of my knowledge, full and correct. I undertake therapy on the understanding that it is a collaborative process, and that progress depends in part upon my own motivation and participation.
Participation
I give Maria Motea full permission to hypnotize me and to use Rapid Transformational Therapy (RTT) knowing that by participating fully in the process and by listening to my personalized recording for 21 days as I play an important role in my overall success.
Guarantee
I understand that although Rapid Transformational Therapy has an incredibly high success rate, Maria Motea cannot and does not guarantee results since my own personal success depends on many factors that Maria Motea cannot control over, including my willingness and desire to affect the changes inside of myself.
Audio Recording(s)
I give Maria Motea full permission to make audio recordings that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s), Maria Motea retains full copyright over any forms of media that may be produced and distributed to me.
Deepening Process
(in-person) I hereby grant permission to Maria Motea to respectfully lift my arm, touch my shoulder, or rock my head during my Rapid Transformational session(s) in order to help facilitate the deepening process.
Confidentiality
By signing this form, I consent that Maria Motea may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested. I also understand that, at any time, Maria Motea may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise.
Cancellation
I accept that all appointments not cancelled within 48 hours notice will be charged in full. I also understand that my investment in this RTT session is non-refundable.