Liability Wavier & Consent Form

Intake Form & Liability Waiver

Please fill out completely.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What are you hoping to achieve through our sessions together?*
On a scale of 0-10, with 0 being non existent how would you rate the current level of the issue you'd like to work on.*
Do you have any spiritual foundations & beliefs that you would like me to be aware of?
What Modalities, if any, have you already tried to reach your goals?*
Do you have any medical or psychological diagnosis relevant to our session that I should be aware of? (write none if not applicable)*

Disclosure of Services

Your initials acknowledge agreement and understanding of each term
Louisa Jovanovich

Qualifications:

Certified Clarity Catalyst Trainer (Masters Degree course Based from Stanford University program) 8 Week live sessions

Certified Master Hypnotist

Completed The Landmark Forum

Completed Gratitude Training Leadership course

Completed HCL Leadership Training

Coached for HCL Leadership Training

Published Author of The 13 Steps to Riches

Podcast Host: Conscious Conversations with Louisa

Continuing Education:

Clinical Hypnotherapy with Hypnosis Motivation Institute
I understand Louisa Jovanovich IS NOT Licensed, certified or registered by the state as a healthcare professional, and does not treat, diagnose or cure any psychical, mental or emotional disorders.   *
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The purpose of a program of hypnotherapy is for vocational and avocational self-improvement and as alternative or complementary treatment to healing arts services licensed by the state. A hypnotherapist is not a licensed physician or psychologist, and hypnotherapy services are not licensed by the State. Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures.
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I understand that holistic therapy interventions are not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my primary healthcare provider for any condition I may have, or health conditions that may arise. *
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I understand and agree that it is my responsibility to discuss any recommendations made with my primary care physician, obstetrician gynecologist, pediatrician, or other board certified physician.
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The use of hypnosis could elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis will be distorted or misconstrued. Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client.
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While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in therapy.
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I understand that I am under no obligation to follow any recommendations given and that any and all of my actions following or resulting from a session are of my own free will.  *
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I have informed the practitioner of all my known physical and medical conditions, and I will keep the practitioner updated of any changes. I will notify the practitioner should I become pregnant of if I am trying to become pregnant. *
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I understand that if I need assistance for a mental or physical health disorder, it is my responsibility to see a licensed psychotherapist, psychiatrist or doctor who specializes in that disorder. *
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I have read and understand this consent to treatment. I have been informed about the risks and benefits of holistic therapy procedures. I intend this consent form to cover this and any subsequent session or course of sessions*
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I understand Louisa Jovanovich is covered by professional liability insurance. This insurance provides coverage for any injury caused by an act or omission on my part while delivering complementary and alternative health-care services.
If you have any questions regarding my coverage or the scope of my services, please feel free to ask.
1. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

2. I or my representative(s) agree to fully release and hold harmless Jasmine Riley-Smith from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).”

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation immediately.

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLES Jasmine Riley-Smith, their officers, officials, agents and/or employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and leasers of premises used for the activity, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
I have received a copy of this disclosure and understand the information described above. I have read the biography above and understand the Hypnotherapists education, training, experience and other qualifications regarding the services to be provided.
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Date

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Your signature indicates understanding and agreement of above policies & liability release*

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Each session $200
ACKNOWLEDGEMENT OF SERVICES AND FEES. Self-Improvement Program. I, acknowledge that I understand and agree to the following: I agree to pay you, Louisa Jovanovich, a fee of $200 per Hypnotherapy session. I also agree to pay you for your services, in full, before date of each session. I agree to give you 24 hours notice for all cancellations or changes of scheduled appointments. I understand that missing a scheduled appointment without prior cancellation, or cancelling with less than 24 hours notice, may be charged to me at the current full rate. I understand that the program of conditioning offered by you will include an undetermined number of private sessions, depending on my individual needs. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-Improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professions Code 2908). The determination to initiate and/or terminate the therapy relationship can be made at any time by client or therapist without the need for detailed explanations. I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of my sessions.
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Intake Form & Liability Waiver

Disclosure of Services