TERMS & CONDITIONS
Margot Gedert has advised me of the scope of hypnotherapy and embodied self-inquiry as a helpful therapeutic technique for a variety of conditions, and I give my full consent to receiving hypnotherapysessions by Margot Gedert in today’s session and in any future sessions.
I understand that results may vary and that the above-named practitioner may not guarantee results.
I understand that the complementary and alternative health care practitioner is a facilitator of hypnotherapy and embodied self-inquiry and is not practicing any other profession that requires a license in New Mexico or Colorado.
The treatment to be provided by the practitioner is complementary or alternative to health care services provided by health care practitioners licensed by the state of New Mexico or Colorado.
I am aware and understand that in some cases meeting in person it may be necessary for the practitioner to respectfully touch my hands to assist me in relaxation. I give the practitioner permission and consent to do so to help me establish a beneficial state of relaxation. I understand that contact of a sexual nature or without consent in never appropriate or legally permitted.
I agree that I am free to terminate any or all sessions at any time.
I have agreed to participate in each session to the best of my ability.
I understand that no one can be hypnotized, or do anything under hypnosis that is against their will. Hypnosis is a collaborative effort between subject and hypnotherapist.
I have accurately provided background information as requested by Margot Gedert.
CONFIDENTIALITY
I understand that a complete notice of Privacy Practices is available upon my request.
I agree that matters regarding my sessions will be kept confidential except in the following circumstances:
I grant specific permission to release information to a specific individual or agency;
I am an imminent danger to myself or others or someone is endangering me;
child or elder abuse is suspected;
or in the case of the subpoena of records.
From time to time Margot Gedert consults with other colleagues, but in this
circumstance clients are not identified by name. My signature below constitutes giving permission for such consultations. I understand that confidentiality regarding my sessions will be honored between Margot Gedert and me. This same confidentiality is respected when working with minors. I understand that complete explanation of HIPAA privacy practices are available at my request.
I understand that, depending on the state of my mental health, further psychological treatment may be needed and will be suggested to me and documented by Margot Gedert if she determines my situation to be outside the scope of hypnotherapy and embodied self-inquiry.
Reports requested by physicians or other practitioners will not be released without my permission.
I understand that I have a right to complete and current information concerning Margot Gedert's assessment and recommended complementary and alternative health care services that are to be provided, including the expected duration of the complementary and alternative health care services to be provided and the patient’s right to be allowed access to my records and written information from my
records.
FEES AND PAYMENTS
The typical charge for a private session is $90 -$110 USD sliding scale per 1-hour session.
Payment is due before each session or upon the conclusion of each session.
Insurance is not accepted.
CANCELLATIONS
I understand that I may be charged $35 for cancellations received less than 24-hour notice unless we can reschedule the appointment.
REPORTS AND PHONE CALLS
There is no charge for email correspondence and brief calls. Calls lasting longer than 15 minutes may be charged and billed to the client on a prorated basis for $1.00 per minute.
My signature below attests to the fact that I consent to the use of embodied self-inquiry and hypnotherapy in my treatment with Margot Gedert.
CONSENT:
I, the undersigned, understand all questions and verify that all information is complete and accurate to the best of my knowledge. I understand that the guide/hypnotherapist does not treat, prescribe or diagnose any condition. I also understand that these embodied self-inquiry & hypnotherapy sessions are not a substitute for medical or psychiatric treatment. I understand these methods to be a learning process, whereby the individual is taught to use their own awareness and perspective for their benefit and well being. With this understanding, I hereby grant Margot Gedert to use self-inquiry or hypnosis techniques with me or the minor child whose name appears at the top of this form.