Client Participation Agreement
Andrew Green, CHt – 555 E 4500 S Murray, UT
Are you currently taking any medications?
, and if Yes, please state for what
As I enter into this relationship, I agree to the following:
1. I am participating in hypnosis by my own choice because I want to be here. 2. I understand that I am not a patient, but a co-operator in my hypnosis experience. 3. I acknowledge the futility of blame for both myself and for others. 4. I understand that my progress here involves how I care for myself physically, mentally, emotionally and spiritually. 5. I understand that transformation is a process and that it can take time.
*** By signing this form I acknowledge that I will give a 24-hour notice in case I need to cancel or re-schedule my appointments and that if I do not- I will pay for the full price of the session that I had scheduled.
As your hypnotherapist, my commitment to you is that I will utilize all of my skills to help you to reach your goals in the shortest time possible. You have my assurance of my full integrity, professionalism, confidentiality and respect.
Contact Information: My name is Andrew M. Green. I can be contacted through my office at 555 E 4500 S Murray, UT or by telephone at (801) 651-4911
Education and Training: Andrew Green is an active member with the International Association of Interpersonal Hypnotherapists and a graduate of the Institute of Interpersonal Hypnotherapy; one of the most comprehensive Hypnotherapy trainings in the country, I am well- trained in Eye Movement Therapy, Hypnotic Programming, Modified Gestalt Therapy, Hypnotic Regression, Holotropic Breathwork, as well as Neuro-Linguistic Programming and other related modalities. Beginning in 2015 Andrew now serves as a Director on the faculty of the Institute as a teacher and trainer in Salt Lake City, UT.
Notice: AS THE STATE OF UTAH 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 neither 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 to another practitioner. A client has a right to refuse hypnotism services at any time. A client has a right to be free of physical, verbal or sexual abuse. A client has a right to know the expected duration of sessions, and may assert any right without retaliation.
Redress: I am a certified member of the International Association of Interpersonal Hypnotherapists, and practice in accordance with its Code of Ethics. If you have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the International Association of Interpersonal Hypnotherapists at Anahat Education Group, Inc. One Tampa City Center 201 N. Franklin Street, Suite #3415 Tampa, FL 33602 (Complaints must be in writing setting forth the basis of the claim Other services than my own may be available to you in the community. You may locate such providers in the telephone book or online. As my client you have the right to refuse any aspect of services or to completely terminate services at any time, or to choose another practitioner.
Fees: The charges for my services are $80 per hour. Sessions may run from 1 to 2 hours. Fees are due at the time of each session in the form of cash, check or credit card. You will be given a 14-day notice of any change in fees. I do have a 24-hour cancellation policy and clients are charged for one and a half hours of time if they do not call to cancel or reschedule in accord with this 24-hour notice. Hours paid in advance in the form of package deals are good for 6 months from their time of purchase. After 6 months of absence from therapy, these hours are forfeited. Packages are non-refundable. 6 hours paid in advance grants a 5% discount. 10 hours paid in advance grants a 10% discount. 20 hours paid in advance grants a 15% discount.
Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you. As my client you have the right to complete and current information concerning any aspect of the professional/client relationship.
Insurance: I suggest you think of my services as something that you will pay for personally. That will both protect your privacy and help you value the work you are doing more. In general, most insurance companies do not like to cover hypnotic services, and I caution you not to expect them to do so.
My Approach: It is my goal to help you to achieve lasting results through the use of Hypnosis, NLP, Meditation and other related self-help modalities. Through the power of your own mind, I will assist you in reaching your goals in a way that you and I both agree to be in your best interest and in a way that is in compliance with state and federal laws, as well as with the standards of the organizations to which I belong. I agree to use my experience to facilitate the changes as are mutually agreed to be in your best interest. I am professionally committed to mobilizing your inner resources in the shortest time possible.
I am of legal age and in consideration of my acceptance as a participant in these hypnosis related services. I for myself, my heirs, executors, administrators and assignees, do hereby release and discharge Andrew Green, any of his employees or other participants from all claims of damages, copyright, demands or actions whatsoever in any manner arising from or growing out of my participation. I have received and read this Client Bill of Rights and the A.C.H.E. Disclosure Form and understand what I have read:
Client Bill of Rights- Client Copy
Contact Information: My name is Andrew M. Green. I can be contacted through my office at 555 E 4500 S Ste. 250-C, Murray, UT or by telephone at (801) 651-4911
Education and Training: Andrew Green is an active member with the International Association of Interpersonal Hypnotherapists and a graduate of the Institute of Interpersonal Hypnotherapy; one of the most comprehensive Hypnotherapy trainings in the country. He is well- trained in Eye Movement Therapy, Hypnotic Programming, Modified Gestalt Therapy, Hypnotic Regression, Holotropic Breathwork, as well as Neuro-Linguistic Programming and other related modalities. Beginning in 2015 Andrew now serves as a Director on the faculty of the Institute as a teacher and trainer in Salt Lake City, UT as well as Los Angeles, CA.