Personal Data Records and Release

Please fill out this information as completely as possible. All information is treated as confidential and will not be released except per your request.

Please Read the following Terms and Conditions and Advisements.

Terms and Conditions

CONFIDENTIALITY

Matters regarding your sessions will be kept confidential except in the following circumstances: You grant me specific permission to release information to a specific individual or agency; child abuse; you are an imminent danger to self or others; or in the case of the subpoena of records. Any information shared is kept confidential. From time to time, I also consult with other colleagues, but in this circumstance, clients are not identified by name. Your signature below constitutes you giving permission for such consultations.

FEES AND PAYMENTS

Payment for individual sessions is due at the conclusion of each session. Payment for discount packages is due in full prior to the first session in the package.

CANCELLATIONS

Since I have reserved our appointment time for you, it is my policy to charge for cancellations received less than 24 hours notice unless we are able to reschedule the appointment within the same week. If you do not, you understand that you may be charged a fee for the missed appointment.

REPORTS AND PHONE CALLS

There is no charge for brief calls. Calls lasting longer than 20 minutes will be charged to the client on a prorated basis. Reports requested by insurance companies, physicians, etc. will not be released without your permission.

ADVISEMENTS

I have been advised by Cindy Locher, BCH and/or Jody Kimmell, CHt, of the scope of hypnosis/hypnotherapy practice and I give my full consent to receiving hypnosis/hypnotherapy sessions. I understand that results vary and that the above name practitioner may not guarantee results. Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Hypnotist/Hypnotherapist does not treat, prescribe for or diagnose any condition.

I understand that the practitioner is a facilitator of hypnosis or hypnotherapy and is not practicing any other profession that requires a license under the laws of the State of Minnesota.

I am aware and understand that in some cases it may be necessary for the practitioner to respectfully touch my shoulder(s), hand, wrist, or forehead in order to assist me in relaxation. I give the practitioner permission and consent to do so in order to help me establish a beneficial state of hypnosis.

I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability.

I have accurately provided background information as requested by the hypnotist/hypnotherapist.

I understand that confidentially regarding my sessions will be honored between my hypnotherapist and me. This same confidentially is respected when working with minors under the age of eighteen.

Please fill out the form below. When you are finished with the form, click Submit at the bottom of the page.

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  4. Gender
  5. How did you hear about ChangeWorks Hypnosis Center?
  6. Have you been hypnotized or used other mind-body techniques before?
  7. Life Ecology Evaluation - Please rate your satisfaction in each area of your life
  8. Health
  9. Anger
  10. Sexuality
  11. Weight
  12. Chronic Pain
  13. Anxiety
  14. Emotional Stress
  15. Work Related Stress
  16. Financial
  17. Procrastination
  18. Habits
  19. Fears/Phobias
  20. Sleep
  21. (required)
 

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