Hypnotherapy Intake Forms
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I look forward to working with you!
Client Intake Form
Coaching and Hypnotherapy Disclosure
The following disclosure is intended to fully inform all clients regarding receiving alternative health care, as well as to fulfill the requirements of California Senate Bill #SB577, passed September 2002, affecting all non-licensed helping professionals offering alternative health care in California.
I, Katherine Simons, am not a licensed physician or psychotherapist. I am not qualified to diagnose, treat, or prescribe for physical or mental conditions.
The use of Hypnotherapy, Reiki, and Shamanic Practices is alternative and complementary to healing arts services.
The services offered through The Holistic Apothec, LLC, are not licensed by the State of California or any state, but the training I have received has been approved by the International Board of Regression Therapy, The Professional Board of Hypnotherapy, the California Board of Registered Nurses and the California Association for Marriage Family Therapists.
Services offered include Hypnotherapy, Reiki, Emotional Freedom Technique (EFT) and Shamanic Practices, for the purpose of pain management, goal setting, performance enhancement, self-healing, regressing therapy, spiritual emergence issues, trauma, relationship issues, learning enhancement, stress management, career issues, exploring life purpose, personal growth and discovery. None of these services is intended to be a substitute for medical or psychological care. Any issue requiring diagnosis and/or treatment will be referred to a licensed practitioner.
It is the goal of all services provided through The Holistic Apothec, LLC, to provide clients with a safe, non-judgmental and supportive environment where clients can gain insights into established patterns of behaviors and work towards transformation and personal growth. Because all of the services and modalities are based on the empowerment model, all clients do their own works and healing with the guidance of a co-creative facilitator.
I have read and understand the disclosure.
Online Conferencing Sessions
There are potential benefits and risks of video-conferencing limits to client confidentiality that differ from in-person sessions.
Confidentiality still applies for on-line services, and nobody will record the session without the permission from both the client and therapist.
We agree to use the video-conferencing Zoom platform selected for our virtual sessions, and the therapist will explain how to use it.
You need to use a computer, or smartphone during the session.
It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
It is important to use a secure internet connection rather than public/free Wi-Fi.
It is important to be on time. If you need to cancel or change your online appointment, you must notify the therapist in advance by phone or email.
We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation.
If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in the online sessions.
You are responsible for full payment. Payments are made through the Thrivecart link sent via email.