Thanks for visiting Miramontes Life Center. To make this journey as easy as possible for you, we've created a single form comprised of 3 parts for you to complete, which includes all necessary disclosures and intake questions. Thank you and we look forward to speaking with you.

This document is provided to inform you of your rights and responsibilities as a client and to help with any questions you may have regarding your therapeutic treatment. Please feel free to express any concerns or questions you have currently.

Please complete this single form, which includes all necessary disclosures and intake questions.

My Approach

The goal of the Miramontes Life Center (MLC) is to help others experience self-empowerment, to make positive life changes and harness the power of the mind for wholeness and holistic well-being. By helping a client expand their awareness and identify the root cause and gain insight that will play a role in their release of the problem. Clients who have a strong desire for change will become self-empowered and achieve desired goals for lasting success and personal transformation.

At our initial consultation or meeting, together we will discuss your needs and concerns to collaboratively decide if we can work together. Maintaining professional boundaries for both client and I is a vital component in therapeutic relationships. Ultimately, you, the client, must decide to put therapeutic and positive suggestions into action. I will use therapeutic approaches based on the problems you present.

If I initiate terminating therapy with you, it will be because I feel that I am not able to be helpful or a higher level of care is needed. Ending therapy well is important. We reserve the right to refuse hypnotherapy services at our discretion. 

Length Of Service

The sessions begin at the hour and last 60 to 90 minutes or longer. The duration of the session varies among clients depending on their needs. You have the right to terminate therapy at any time during your session.

Online & Remote Therapy Release

Remote therapy involves receiving therapy sessions remotely via live video link. The link will allow you, the client, to speak with me and allow me to monitor the safety of the client. Acknowledging that I cannot be held responsible for providing care in the event of an emergency. Emergency situations that are outside the scope of my responsibility include but are not limited to suicide risk assessment and other emergency situations that require immediate care. If you receive a remote therapy session and have symptoms requiring medical attention, please contact your primary care physician or local ER for assistance.

Authorization for Release of Client Information

If you wish to authorize the release of your client information to any individual or entity, please complete this authorization form.

Recording of Sessions

I (MLC Hypnotherapist) have Client’s permission to record your Hypnotherapy session (voice and/or Zoom video format).

Physician Consultation

I (MLC Hypnotherapist) have client’s permission to discuss their case with referring physician, if appropriate.

Hypnotherapy Session Rates

Note: Introductory rates may be available at times prior to the start of Hypnotherapy services.  

60 - 90 minutes - $175

MLC is a charge collecting provider and does not accept insurance or bill for ICD 10 codes. MLC will provide an invoice/receipt for reimbursement. Method of payment accepted include cash, credit, debit, Venmo, and Zelle. Fee is charged prior to the session.

Note: Hypnosis with a Letter of Medical Necessity (LMN) is eligible for reimbursement with a flexible spending account (FSA), health saving account (HAS), a health reimbursement arrangement (HRA).

Refund Policy

The practice of hypnotherapy and other holistic disciplines does not guarantee therapeutic outcomes, MLC offers no refunds and only credit for any unused portion of any multi-session program.

Confidentiality

My client’s confidentiality is important, and MLC will keep confidential anything you discuss as a part of our therapy relationship. Circumstance in which I am required to break confidentiality:

1. Client consent written or verbal to disclose information to another individual or entity, such as Medical / Health professional, insurance company, or family member.
2. A client is a danger to oneself or others.
3. A client disclosed information that leads me to believe a child, disabled individual, or elderly is being abused or neglected.
4. Ordered by the court to disclose information, such as client involvement in a criminal or custody dispute.

Missed Appointments / Cancellation Policy

We ask that you give MLC at least 24 hrs. notice if you must cancel. Please be advised that a $25.00 fee will be charged for a missed appointment or no-show cancellation with less than 24 hrs. notice. The therapist(s) must adhere to this policy and cannot make any exceptions unless an emergency prevents attendance. Your cooperation is appreciated and thank you in advance for understanding.

The information below has been read by me and explained to me as required:

I understand my responsibility for the payment of any charges for canceled or missed appointments.

I understand, in order to receive the most benefit from the session(s), it is important that you are committed to personal transformation and self-care.

I am aware that the practice of hypnotherapy and other holistic disciplines do not constitute exact science and acknowledge that no guarantees have been made to me as to the result of therapy by the evaluation of MLC therapist(s).

I understand that for certain therapy methods deemed appropriate by the therapist, I will be required to sign a consent form. Furthermore, if I do not fully understand the therapy treatment risks, consequences, or alternative methods of therapy, I have the right to question the appropriate therapy professionals.

I understand that MLC shall not be responsible or liable for damage to any personal property.

I understand the content of all therapy sessions are private and confidential. All verbal and written documentation about my information is not to be shared with another party without me or my legal guardian’s written consent.

I, the client, understand that I am free to terminate the treatment process at any time by giving the appropriate notice with respect to the therapeutic relationship and the cancellation policy mentioned above.

Hypnotherapist agrees to provide professional services in accordance with acquired training and experience giving undivided attention during scheduled consultations to facilitate Client’s benefits. Hypnotherapists work is Client centered. Services provided utilize induction of hypnosis, and methods and principles used to help Clients discover their inner creative abilities to develop positive thinking and feeling and to transform undesirable habit and behavior patterns. Therapeutic goals are to achieve freedom from restrictive thought and belief systems, to assist in solving personal problems, developing motivation, and achieving goals. Client may be taught the use of self-hypnotic techniques to assist in achieving goals and resolving issues that have been mutually agreed upon by Client and Hypnotherapist. 

Hypnosis is not a state of sleep but is a natural state of mind that can produce extraordinary levels of relaxation of mind, body, and emotions. The principles and theories upon which hypnotherapy is based are accessing and utilizing the power of one’s inner resources. Hypnosis can transcend the critical, analytical level of mind, and facilitate the acceptance of suggestions, directions and instructions desired by the Client. The therapeutic use of hypnosis can also elicit information and insights from the inner mind. The Hypnotherapist utilizes interviews, discussion and hypnotic methods dealing with underlying issues whenever appropriate, with the goal of achieving effective and lasting results.

Services to be provided do not include the practice of medicine, as Hypnotherapist is not a licensed physician. These services are non-diagnostic and are complementary to the healing arts services that are licensed by the state. The California State Legislature has determined that state licensing may not be conferred upon an occupational group for purposes of status or prestige. The primary purpose of licensing laws for legally defined Healing Arts and Mental Health professionals is to protect public health and safety. Accordingly, Hypnotherapists are not issued licenses by any state governmental agency to engage in their professional services. 

I, Ray Miramontes, CMH/CHt, have acquired the following education, training experience, and qualifications to perform the services offered to my Clients:

A Master’s degree and Certified Hypnotherapist Level I & II, Advanced Techniques of Hypnosis I & II, Hypnotherapy with Children, Hypnosis and Therapeutic Psychology, Clinical Hypnosis, and Techniques of Regression awarded through St. John’s University, Murrieta, California. Medical hypnotherapy certification earned from UP Hypnosis Institute. Certified Hypnotherapist and Board Certification through the International Medical and Dental Hypnotherapy Association (IMDHA).

For complaints not resolved by Hypnotherapist, contact  the International Medical and Dental Hypnotherapy Association at staff@imdha.com.

I, the undersigned Client acknowledge that I have been advised of the foregoing information, and that I have been given a copy of the “Client Information” form.

Hypnotherapy is a self-regulated profession and does not qualify for State licensing. The International Medical and Dental Hypnotherapy Association (IMDHA) is a professional organization, chartered by the state of Pennsylvania, to establish training standards, standards of professional practice, and a code of ethics. The IMDHA can suspend or revoke certification. Certification is awarded to those who attend state licensed schools, with approved hypnotherapy instructors. Although the state does not regulate curriculum or a required number of hours of training, IMDHA has the highest requirements for certification of any major Hypnotherapy organization in the USA and internationally.  The IMDHA logo is a Hallmark of Quality for the Hypnotherapy profession.

CONSENT TO LEAVE VOICEMAIL MESSAGE: I understand as a part of my therapy and care, Miramontes Life Center may need to reach me by phone. To provide effective care, I authorize Miramontes Life Center therapist/staff to leave a detailed voicemail regarding treatment and plan of care, using a personal telephone number I have provided.

CONSENT TO PROVIDE INFORMATION BY EMAIL: I understand that Email is not considered to be a confidential form of communication. I also understand as a part of my therapy and care, Miramontes Life Center may need to communicate with me via Email. To provide effective care, I authorize Miramontes Life Center therapist/staff to send me information, as required, regarding treatment and plan of care, using the Email address(es) I have provided.