Waiver of Liability
I, (the Client), agree to release ALANA BASAMANOWICZ (Hypnotherapist CHT & REIKI MASTER TEACHER Practitioner), of any responsibility or injury occurring from my session(s).
You affirm that Hypnotherapy and or Reiki is appropriate for you and does not conflict with existing medical or psychiatric treatment. Always seek and follow the advice of your physician or other professional medical practitioner before considering alternative treatment.
Hypnosis methods used are designed to facilitate the client’s quest
for self-improvement and relaxation. Specific additional techniques may include: Body Relaxation, Directed Meditation, Age Regression, and Guided Imagery.
I understand that Reiki is a simple, gentle, hands-on and hands-off energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.
• Unlicensed Registered Psychotherapist with the Department of Regulatory Agencies (DORA) Colorado
A registered psychotherapist is registered with the State Board of Registered Psychotherapists and is authorized by law to practice psychotherapy in CO but is not licensed or certified, and no degree, training or experience is required from the state.
• DORA License Info: #NLC.0105525 (1560 Broadway Suite-1350, Denver CO (303) 894-7766)
•2014 - Certification in Transformational Hypnotherapy from Eastburn Institute of Hypnosis, Westminster CO
•2018 - Usui Tibetan Reiki Master & Teacher Practitioner, Instructor: Ann Bibey, Fort Collins CO
•National Guild of Hypnotist (NGH)
•International Association of Reiki Professionals (IARP)
•Professional Liability Malpractice Insurance
Client Privacy Information and Participation Agreement
Confidentiality of Information: Clients have a right to expect that information revealed in sessions not be disclosed without extraordinary justification. The conditions that justify the release of information and by law must be reported to the appropriate agencies, are the following: In other situations, signed authorization for release of information is required.
Knowledge of child abuse or neglect.
Knowledge of senior citizen abuse or neglect.
A client poses a serious risk of suicide and is an imminent danger to self.
A client poses a threat of imminent danger to another person.
A Judge, by issuance of a court order, may obtain information.
Report to law enforcement authorities knowledge of a felony that has been, or is being