Hypnosis Consent Form

1. Description of Services- You, the undersigned client, understand and acknowledge that hypnosis is a voluntary, self-help, and therapeutic process where a Certified Hypnotist facilitates relaxation, focus and heightened awareness to help individuals access their subconscious mind. Hypnosis is designed to promote positive behavioral change, but it is not a substitute for medical treatment, mental health therapy, or any form of licensed healthcare.

   
   

   I, Sabrina Hansen, MSW, CH am not a licensed medical or psychological professional. I do not diagnose, treat, or cure any medical or psychological condition, and my services are not intended as a replacement for professional healthcare. I recommend that you consult a licensed healthcare provider for any physical or mental health conditions.

   
   

   Notice: AS THE STATE OF VIRGINIA HAS NOT ADOPTED EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM, THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY. Hypnotism is a self-regulating profession and its practitioners are not licensed by state governments. I am not a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to coordinated transfer of services to another practitioner. A client has a right to refuse hypnotism services at any time.

   
   

2. Acknowledgement of Voluntary Participation- You acknowledge that your participation in hypnosis sessions is entirely voluntary. You understand that you are free to discontinue or refuse participation at any time without penalty. You further understand that results from hypnosis may vary and cannot be guaranteed.

   
   

   You also acknowledge that hypnosis involves a cooperative process, where the outcome largely depends on your personal openness, willingness, and receptivity to the suggestions provided. I, Sabrina Hansen, MSW cannot control or guarantee specific outcomes, nor can I ensure any changes in behavior or mindset beyond the services provided.

   
   

3. Limitation of Liability- You hereby release and discharge Sabrina Hansen, MSW, CH, the Relational Mastery Institute, and any affiliated parties from all claims, demands, or liabilities of any kind arising from your participation in hypnosis sessions.

   
   

4. No Medical or Psychological Advice- You understand that hypnosis is not intended as a substitute for medical treatment or mental health counseling. You affirm that you have been advised to consult with your physician or licensed mental health professional if you are currently under their care or have concerns about your health. You also affirm that you are not currently experiencing any condition (mental or physical) that would make participation in hypnosis inappropriate.

   
   

   If you have a diagnosed medical or psychological condition, or if you are under the care of a licensed healthcare professional, you affirm that you have obtained clearance from your healthcare provider before participating in hypnosis sessions.

   
   

5. Confidentiality- I will not release any information to anyone without a written authorization from you, except as provided for by law.

   
   

6. Assumption of Risk- By signing this consent form, you assume full responsibility for any risks, known or unknown, that may arise during or after your participation in hypnosis sessions. You agree to indemnify and hold harmless Sabrina Hansen, MSW, the Relational Mastery Institute, its officers, employees, and affiliates from any claims, damages, or legal actions that may result from your participation, including any costs associated with defending against such claims.

7. Fees, Referrals & Payment Policies-

• Prices can vary depending on the therapy/intervention used and the duration of each session.

• Payment is due at the time of service unless otherwise arranged in advance.

• A 24-hour notice is required for cancellations or rescheduling. Failure to provide notice may result in a cancellation fee.

• Referral: Clients may be asked to provide a referral from their physician or health care professional. 

8. Children- Appointments for children under the age of 18 require written permission from parent or guardian who must accompany the client at the first session, unless there is a mutual agreement beforehand.

9. Recorded Sessions- I understand that parts of the hypnotherapy sessions may be recorded to enhance the client experience and progress, as well as for record keeping purposes.

10. Redress- I am a certified member of the National Guild of Hypnotists, and practice in accordance with its Code of Ethics and Standards. If you have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the National Guild of Hypnotists at P.O. Box 308, Merrimack, NH 03054-0308, (603) 429-9438, to seek redress. Every member of the National Guild of Hypnotists provides this information to every client to insure ethical practice.

11. Acknowledgment & Consent- I, [Client Name], acknowledge that I have read and understood the information provided in this consent form. I understand that hypnosis is a collaborative process and that the outcomes depend on my active participation. I consent to receive hypnosis services from Sabrina Hansen, MSW, CH under the terms outlined above.

By signing below, I confirm that I have had the opportunity to ask any questions and that I agree to the terms of this agreement.