Hypnotherapy Intake Form

CLIENT AGREEMENT

Please read and sign where applicable
I, First Name* Last Name* give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.
I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk.

I also understand:

1. That massage therapy and/or acupuncture
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow; and
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
2. That the massage therapists and/or acupuncturists
- do not diagnose illness, disease or any other physical or mental disorder;
- do not prescribe medical treatment or pharmaceuticals; and
- do not perform any spinal manipulations.
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

If I need to reschedule due to illness or Covid exposure, I agree to contact the Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
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POLICIES

Welcome! Thank you for choosing The Teal Center!

Please read and initial each of the following:
Initials* Appointments missed, cancelled or rescheduled with less than 24 hours notice will be charged 50% of the session fee. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are sent 48 hours prior to the scheduled appointment.
Initials* The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to The Teal Center.
Initials* If you have a cold or other contagious illness, please call us before your so we can check with your therapist to see if it is appropriate for you to come in.
Initials* In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.
Initials* Tips are appreciated but never expected. If you wish to leave a gratuity, we ask that you do so in cash or by check made directly to your therapist. Gratuity is also made possible via the Venmo app for some therapists.
Initials* If you move or change numbers, it is your responsibility to inform us. This is important information so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.
Initials* The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.
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Hypnosis Intake Form