If you are coming in for your first hypnotherapy session, please print these forms out, sign, take a photo or scan, then send them to me before the time of your appointment. The email contact info should be in the confirmation letter you receive once you’ve booked. If you need to have these documents emailed to you, please specify in your notes when you book the appointment.
Forms I & II are always needed for the very first session. Form III is only for sessions involving medical issues, such as pain management. Form III is not required for smoking cessation or weight loss.
I. DISCLOSURE OF SERVICES
In recognition that millions of Californians receive a substantial volume of healthcare services from complementary and alternative health care practitioners, California Law allows access by California residents to complementary and alternative healthcare practitioners who are not providing services that require medical training and credentials. The following disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code.
The purpose of a program of hypnotherapy is for vocational and avocational self-improvement (Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state. A hypnotherapist is not a licensed physician or psychologist and hypnotherapy services are not licensed by the State of California. Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures.
Hypnosis works with the power of the subconscious mind to change habits and behaviors. The subconscious mind is considered to be the source or root of many of our behaviors, emotions, attitudes and motivations. Hypnosis is believed to be a powerful tool for accessing the subconscious mind and creating improvements in our lives.
Services consist of a program of conditioning, including an undetermined number of private sessions, depending on the client’s individual needs. The hypnotist will to the best of his or her ability endeavor to accomplish the objectives of the client’s sessions. While hypnosis may be an effective technique for many purposes, the effectiveness may vary from individual to individual, and no specific results or progress can be promised or guaranteed.
During hypnotherapy sessions, clients remain completely aware of everything that is going on. In fact, many people experience a hyper-awareness where sensations are perceived enriched and vivid. The ability to visualize or imagine is enhanced. Deep relaxation is common. Many describe the hypnotic state as a complete and total escape from physical tension and emotional stress, while remaining completely alert.
The use of hypnosis could elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis will be distorted or misconstrued. Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client. While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in therapy.
I have received a copy of this disclosure and understand the information described above. I have also read on the other side of this document a biography of the Hypnotherapists education, training, experience and other qualifications regarding the services to be provided.
Client Name (please print): _____________________________
Client Signature: _____________________________
Date: ___________________
II. ACKNOWLEDGEMENT OF SERVICES & FEES
SUBJECT: SELF-IMPROVEMENT PROGRAM
I, the undersigned,
I also agree to pay you for your services, in full, prior to the date of each session. I agree to give you 24 hours notice for all cancellations or changes of scheduled appointments. I understand that missing a scheduled appointment without prior cancellation, or canceling with less than 24 hours notice, will result in me being charged to me at the current full rate.
I understand that the program of conditioning offered by you will include an undetermined number of private sessions, depending on my individual needs. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-
Additional Conditions: __________________________________
Have you ever had hypnotherapy before?_______________________
What are your goals for this session?______________________
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Emergency Contact_________________Phone Number__________
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Client (Print Name)
_______________________________
Client (Sign)
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Client (Date)
Kyra Oser, C.Ht
Hypnotherapist
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Hypnotherapist (Sign)
______________________________
Hypnotherapist (Print Date)
III. REQUEST FOR MEDICAL REFERRAL
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Date
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Physician Name
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Physician Signature
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Physician Address
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City State Zip
To Whom It May Concern:
_________________ is seeking my services in 201_ for hypnotherapy to achieve self improvement goals. As a Hypnotherapist, I offer vocational or avocational self-improvement, or work under referral of Doctors, Dentists or Psychologists. Because one or more of their stated goals may have a physiological basis, I am referring them to you for examination and referral. (Business and Professions Code 2908)
I ask for your referral for this client, not as your endorsement of hypnosis, but rather as your confirmation that you are aware of your patient’s symptoms and goals and do not feel that seeking hypnotherapy for motivation to achieve those goals would in any way interfere with any necessary medical treatment or that hypnotherapy is in any way medically contraindicated for your patient.
I welcome your recommendations and referral so that I may be of continued service to my client. Your prompt reply is greatly appreciated.
Thank you.
Kyra Oser, C.Ht
23371 Mulholland Dr., Ste. 271
Los Angeles, CA 91364
www.kyraoser.com
