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Please click on disclosure form link at left to fill out and scan and send back to me. via email: alexaniko@hotmail.com You may also bring the form with you to our appointment.
This is the text: INTAKE FORM Transformative Energy Works Name: Address: Telephone: Email: Date of Birth: ****************************************************************************************************************************************** Hypnotherapy Disclosure Form Alexandra Louise Clark CHT, M.Ed (hereafter “Hypnotherapist”) agrees to provide professional services in accordance with acquired training and experience to facilitate the client’s attainment of treatment goals. Hypnotherapy is a client-centered approach which promotes the rapid accomplishment of precise cognitive or behavioral goals. Hypnotherapists Training: Certified hypnotherapist, Transpersonal Hypnotherapy Institute, Denver CO M.Ed Counseling (College of William and Mary, Williamsburg, VA), BS Psychology (Virginia Tech), Virginia, USA BA Hons Spanish (Bristol University, United Kingdom) Registered psychotherapist DORA Colorado Reiki Master Waiver of Liability By signature, the client named below voluntarily agrees to be the recipient of hypnotherapy sessions, and accepts full responsibility for any and all effects arising from the hypnotherapy, past life regression and energy work sessions. The client shall hold Alexandra Louise Clark CHT, M.Ed harmless for any possible physical or mental effects of hypnotherapy/feedback sessions and energy work sessions. Disclaimer Services to be provided do not include the practice of medicine. The Hypnotherapist is a trained Hypnotherapist, not a medical doctor. At no time will the Hypnotherapist attempt to provide medical treatment. The client affirms that hypnotherapy is appropriate for them and does not conflict with existing medical or psychiatric treatment. Always follow the advice of your doctor or other professional medical practitioner. Do not discontinue medication without the advice of your MD. I have had the opportunity to ask questions about hypnotherapy and past life regression. I acknowledge that I am not suffering from any mental health disorder that would preclude hypnotherapy or energy work. I am in good physical health. I understand that the Hypnotherapist will maintain complete confidentiality of our sessions together. I acknowledge the desire to receive hypnotherapy, the exploration of past life regression and energy work with Alexandra Louise Clark CHT, M.Ed. I hereby forever and unconditionally release the hypnotherapist from all claims and causes of action related to or arising from hypnotherapy or energy work now or at any time. I, the undersigned Client acknowledge that I have been advised of the foregoing information, and that I have been given a copy of this Disclosure Form. Cancellation Policy Please cancel appointments at least 24 hours before the agreed upon appointment time. A cancellation fee of $50 will apply if sessions are cancelled within the 24 hour time frame. Thank you for your understanding. Signature --------------------------------------------------- --------------------------------------------------- Print Name Date----------------------------------------------- | ||
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