Client Information & Participation Agreement Sandy Fox Hypnotherapy

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Sandra K. Fox, CMS-CHt

Clinical Hypnotherapist
Client Information & Participation Agreement
Name
Date

MonthDayYear
Date
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
I hereby authorize Sandra K. Fox to: (Check all that apply - supply names on right)

Please initial if you agree to the use of e-mail correspondencePlease initial if you agree to receive a customized self-hypnosis MP3 recording via e-mailPlease initial if you agree to receive text messagesPlease initial if you consent to receive voice messages at the above listed phone numbers
Age
Birthdate
Marital Status

SingleDivorcedMarried or in LT RelationshipWidowed
Occupation
Reason for this visit
Have you ever been hypnotized before?

YesNo
If yes, briefly explain your experience below:
Medical conditions or challenges:
Are you currently under a physician’s or medical practitioner’s care for any of the above conditions?

YesNo
If so, name of physician(s) or medical practitioner(s):
Date of last visit:

MonthDayYear
Date
Relevance of visit to this consultation:
Have you discussed with your physician your use of hypnotherapy as an adjunct to your medical treatment?

YesNo
Is s/he in agreement with adding this modality to your care?

YesNo
Are you currently taking any prescription medications?

YesNo
If yes, please list them with dosage, frequency, and how they affect you:
Have you ever been in therapy or counseling before?

YesNo
If yes, give a brief history of your mental health treatment and the results of your treatment:
Are you currently in therapy/counseling?

YesNo
If yes, name of mental health professional:
Is your therapist aware of your desire to seek hypnotherapy?

YesNo
Do you meditate?

YesNo
What are your spiritual or religious beliefs or philosophy of life?
Please check any of the following issues or areas you would like to resolve:

Anxiety/StressAnger/GuiltAccelerated HealingPain ControlBody Image IssuesSelf-confidenceInsomniaSmoking CessationWeight ManagementPublic SpeakingMedical*Fears/Phobias/Trauma RecoveryLack of Motivation/ProcrastinationLow Self-esteem or ShynessFocus & ConcentrationSports PerformanceJob PerformanceSpiritual GrowthTest Anxiety/Accelerated LearningGrief RecoveryRelationship Issues
Please describe any other issues / areas or provide more detail on your Medical Issues:
Hypnotherapy is an educational and self-improvement process that facilitates access to a person’s internal resources to assist him/her in solving problems, increasing motivation, or altering behavioral patterns through hypnosis to create positive change. Hypnotherapy, Self-hypnosis, Regression, and NLP are not absolute sciences. Sandra K. Fox is aware of no cases on record in which an individual has been harmed by the use of these methods. On the other hand, thousands of documented cases exist in which people have benefitted greatly from their use.

Hypnotherapy is not a substitute for medical treatment or psychotherapy. Sandra K. Fox does not practice medicine or psychotherapy, and her services are not a replacement for counseling, psychotherapy, psychiatric, or medical treatment. No service or product provided is intended to diagnose or treat any disease or illness, psychological or mental health conditions.

Medical Support Hypnotherapy is used only as an adjunct to conventional medical treatment, and consultation with a licensed physician is required before Medical Support Hypnotherapy services are provided.
Client Information & Participation Agreement (Cont’d.)

Please read carefully and sign:
I understand that all services provided by Sandra K. Fox are for educational and self-improvement purposes only. I further understand that these services are not the practice of medicine or psychotherapy and are, therefore, not offered as a replacement for counseling, psychotherapy, psychiatric or medical treatment.

I affirm that I am of legal age, and in consideration of my acceptance as a participant in this hypnosis, hypnotherapy or neuro-linguistic programming (NLP) session, age regression, or any other service provided by Sandra K. Fox, I, for myself, my heirs, executors, administrators, and assigns, do hereby release and discharge Sandra K. Fox or other participants in any of these activities from all claims of damages, copyright demands, or actions whatsoever in any manner arising from or growing out of my participation in said activities.

I agree that any claim of damages or disputes arising from my participation in hypnotherapy sessions, hypnotherapy regression therapies, processing emotions methods, NLP techniques, HeartMath techniques, guided imagery, or events, should it arise, shall be settled by binding arbitration before an extra-judicial arbitration and mediation service. I further understand that recordings may be made at any of these events, and that Sandra K. Fox and her organization retain the copyright to all of these recordings.
Printed Name Client
Client Signature Date

MonthDayYear
Date
Client Signature:

Clear
Legal Guardian Printed Name
Legal Guardian Signature Date

MonthDayYear
Date
Legal Guardian Signature: (If under eighteen years of age)

Clear
In order to be more successful in reaching my goals, I agree to:
1. Be an active participant in my hypnotherapy experience and see myself as a partner in the transformative nature of this process.
2. Recognize that my thoughts, feelings, images and actions have a direct effect on the quality of my life.
3. Acknowledge that my well-being depends directly on how well I care for myself physically, emotionally, intellectually, and spiritually.
4. Accept that blaming others or myself is totally futile.
5. Take responsibility for my experience of life, because I create my life to the best of my ability in the moment with what I know right now.
6. Be on time for my sessions and allow at least twenty-four hours of advance notice should I need to cancel or reschedule a session (304-673-8474).
I have been informed that Sandra K.Fox is a fellow of the International Board of Hypnotherapy and practices in accordance with its Code of Ethics and Standards. I understand that If I have a complaint about the services I receive and if my complaint cannot be satisfactorily resolved by Ms. Fox, I may contact the International Board of Hypnotherapy at 2132 Osuna Road, N.E., Suite B, Albuquerque, New Mexico, 87113 or at 505-767-8030.

I understand that it is my right to refuse any aspect of the services offered by Sandra K. Fox and to seek the service of another hypnotherapist at any time. By signing below, I agree to pay Ms. Fox’s fee of $150.00 per session, and understand that sessions vary in length from 45 to 90 minutes.
Client Signature Date

MonthDayYear
Date
Client Signature:

Clear
I commit to use my expertise to facilitate the changes that we mutually agree to be in your best interest in the shortest possible time.
Hypnotherapist Signature Date

MonthDayYear
Date
Hypnotherapist’s Signature:

Clear
Confidentiality of Information
I give my permission for my practitioner, Sandra K. Fox, to take notes about me, including health history/medical and/or personal information which I choose to disclose to her in the course of our sessions.

This information will not be disclosed to a third party, including my physician, without my express written consent on a separate “Authorization for Release of Information” form, except in the following instances:

In response to a subpoena from a court or other legal order from law enforcement authorities In cases of reported child or senior citizen abuse or neglect
In the case of imminent danger to myself or others

In any other situations, signed authorization for release of information is required.
Printed Name Client
Client Signature Date

MonthDayYear
Date
Client Signature:

Clear
Hypnotherapist Signature Date

MonthDayYear
Date
Hypnotherapist Signature:

Clear

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Sandra K. Fox, CMS-CHt

Client Information & Participation Agreement (Cont’d.)

Confidentiality of Information