Informed Consent (non-therapeutic hypnosis):
Please print your name in the first space, then sign, print and date below to indicate that you understand what you have read.
I, the ubove stated individual, agree to engage in the process on non-therapeutic hypnosis. I understand that I will have all choices at all times and can start and end the process at anytime, even during my session. The services I am agreeing to are held out to the public as non- therapeutic hypnotism, defined as the learning of self-hypnosis to induce positive thinking, create commitment to change and to learn the techniques of self-hypnosis to produce self-control over physical experiences and emotional awareness, hypnotism has not been represented as any form of health care or psychotherapy, and I may make no health benefit claims for my services.
I agree to continue medication as prescribed by my attending physicians and understand that hypnotherapy is not a substitute for medical care. I understand a hypnotist neither diagnosis nor treats any medical or mental health condition, instead offering tools of self-discovery and awareness to compliment any medical treatment prescribed by a physician. If any medical symptoms progress or become acute I agree to seek medical attention from a licensed healthcare provider. In the event of a medical emergency or if I feel suicidal, I will call 911 or other emergency help.
I understand that the methods of hypnosis include relaxation, breath work, creative visualization, positive affirmation, self-awareness development and other techniques and may produce physical and emotional responses. I agree to inform my hypnotist of any adverse feelings or experiences related to this process, at the time of my awareness of them. I have been informed as to the limits of hypnosis effectiveness and offered referral to other providers of alternative approaches to problem solving. I am over age 18, and consent to hypnosis services offered by A.D. Roberts.