Consent and Disclaimer Form
I have been advised by Connie Madry C.Ht. for the purpose and scope of hypnotherapy and the methods of hypnotherapy to be used in my case and I give my full consent to receiving hypnotherapy sessions by the above mentioned hypnotherapist.
I understand that the results obtained through hypnosis vary with each individual and that no specific results can be guaranteed by the above mentioned hypnotherapists.
I understand that hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling.
I understand that the hypnotherapist does not treat, prescribe for or diagnosis any condition. Nothing said or done by the hypnotherapist should be construed to be such.
I also understand that the hypnotherapist is a facilitator of hypnosis and hypnotherapy and is not practicing any other profession that requires a license under the laws of the State of Michigan.
I understand that in some circumstances, such as hypnosis for glove anesthesia or pain management, it may be necessary for the hypnotherapist to respectfully touch my hand(s), wrist, arms, or shoulder(s). I hereby consent to such touching by the hypnotherapist.
I acknowledge that I am free to terminate any or all sessions at any time, and that I have agreed to participate in each session through my own consent.
I understand that confidentiality regarding my sessions will be honored between my hypnotherapist and myself. Confidentiality is also respected when working with minors or clients under the age of eighteen.
By signing below and submitting this form I hereby affirm under oath that: (1) I am 18 years of age or older; (2) I am the person identified above (or, if the person identified above is a minor, I am the parent or guardian of that person); and (3) the information provided in this form is, to the best of my knowledge, true and correct.
If client is under the age of 18 or under the care of a guardian.