Heal Now


Client Intake Form

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Informed Consent

Client-Hypnotherapist Service Agreement

Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPM), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.

Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

Hypnotherapy is a relationship between people that works in part because
of clearly defined rights and responsibilities held by each person. As a client in hypnotherapy,
you have certain rights and responsibilities that are important for you to understand. There
are also legal limitations to those rights that you should be aware of. I, as your
hypnotherapist, have corresponding responsibilities to you. These rights and responsibilities are
described in the following sections.

Goals of Hypnotherapy

There can be many goals for the hypnotherapy relationship. Here I have a
special interest in help with chronic pain, improving wound healing, as well
as other chronic health conditions. Some other goals may include such
things as improving the quality of your life, learning to live with mindfulness
and self actualisation.

Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behaviour or decreasing/ending drug use. Whatever the goals for hypnotherapy, they will be set by the clients according to what they want to work on in hypnotherapy. The hypnotherapist may make suggestions on how to reach that goal but you decide where you want to go.

Risks/Benefits of Hypnotherapy

Hypnotherapy is an intensely personal process which can bring unpleasant memories or
emotions to the surface. There are no guarantees that hypnotherapy will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Hypnotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. However, there are many benefits to hypnotherapy. Hypnotherapy can help you develop coping skills, make behavioural changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present andmany other advantages.


Appointments will ordinarily be 50-60 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours' notice. If you miss a session without cancelling, or cancel with less than 24 hour notice, you may be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible the cancelation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.


Your hypnotherapist will make every effort to keep your personal
information private. If you
wish to have information released, you will be required to sign a consent
form before such
information will be released. There are some limitations to confidentiality to
which you need
to be aware. Your hypnotherapist may consult with a supervisor or other
hypnotherapist in order to give you the best service. In the event that your
consults with another hypnotherapist, no identifying information such as
your name would
be released. Hypnotherapists are required by law to release information
when the client
poses a risk to themselves or others and in cases of abuse to children or
the elderly. If your
hypnotherapist receives a court order or subpoena, she may be required to
release some
information. In such a case, your hypnotherapist will consult with other
professionals and
limit the release to only what is necessary by law.

Confidentiality and Group Therapy

The nature of group therapy makes it difficult to maintain confidentiality. If
you choose to participate in group therapy, be aware that your hypnotherapist cannot guarantee that other group members will maintain your confidentiality. However, your hypnotherapist will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in group confidential. Your hypnotherapist also has the right to remove any group member from the group should she discover that a group member has violated the confidentiality rule.

Confidentiality and Technology

Some clients may choose to use technology in their hypnotherapy sessions. This includes but is not limited to online hypnotherapy via Skype, telephone, email, text or chat. Due to the nature of online hypnotherapy, there is always the possibility that unauthorised persons may attempt to discover your personal information. Your hypnotherapist will take every precaution to safeguard your information but cannot guarantee that unauthorised access to electronic communications could not occur. Please be advised to take precautions with regard to authorised and unauthorised access to any technology used in hypnotherapy sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your hypnotherapy sessions. Should a client have concerns about the safety of their email, your hypnotherapist can arrange to encrypt email communication with you.

Record Keeping

Your hypnotherapist may keep records of your hypnotherapy sessions and a treatment plan
which includes goals for your hypnotherapy. These records are kept to ensure a direction to
your sessions and continuity in service. They will not be shared except with
respect to the limits to confidentiality discussed in the Confidentiality section. Should the
client wish to have their records released, they are required to sign a release of
information which specifies what information is to be released and to whom. Records will be
kept for at least 7 years but may be kept for longer. Records will be kept either electronically
on a USB flash drive or in a paper file and stored in a locked cabinet in the
hypnotherapist's office.

Professional Fees You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or cash. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.

If you anticipate becoming involved in a court case, I recommend that we
discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required. Fees are non-negotiable. To receive sliding scale fees, you must present proof of income through recent pay stubs or tax forms. Fees are subject to change at hypnotherapist's discretion.

Fee Schedule

  • $235 for first visit
  • $185 for each subsequent visit
  • $700 for four visit pack

If you have a health insurance policy, it will usually provide some coverage
for mental health treatment. With your permission, I will assist you to the extent possible in
filing claims and ascertaining information about your coverage, but you are responsible for
knowing your coverage and for letting me know if/when your coverage changes. You should also be aware that most insurance companies require you to authorise me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information which will become part of the insurance company files. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.

In addition, if you plan to use your insurance, authorisation from the insurance company
may be required before they will cover hypnotherapy fees. If you did not obtain authorisation and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee to be covered by the patient. Either amount is to be paid at the time of the visit by check or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services.

If I am not a participating provider for your insurance plan, I will supply you with a receipt
of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, I will refer you to a colleague.

Contacting Me

I am often not immediately available by telephone. I do not answer my phone when I am
with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If you feel you cannot wait for a return call or it is an
emergency situation, go to your local hospital or call 000.


Hypnotherapist may request client's email address. Client has the right to refuse to divulge
email address. Hypnotherapist may use email addresses to periodically check in with clients who have ended therapy suddenly. Hypnotherapist may also use email addresses to send newsletters with valuable therapeutic information such as tips for depression or relaxation techniques. Hypnotherapist also has a blog and if this is appropriate for the client, hypnotherapist may send information through email about subscribing to the blog or information related to mental health and wellness. If you would like to receive any correspondence through email, please write your email address here: If you would like to opt out of email correspondence, please check here

I Agree

Consent to Hypnotherapy

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