Hypnotherapy Advised Consent Form
Please read the following information and sign below:
I give my full consent to receive hypnotherapy / hypnosis as a treatment modality from Quantum Life Repair (Dr Gary Danko), who has discussed with me how he intends to use hypnosis and the appropriate expectations regarding its use. I agree to the following terms:
1. I have been informed as to how hypnosis / hypnotherapy will be used.
2. I have been informed as to the appropriate expectations regarding the use of hypnosis/ hypnotherapy.
3. I understand that results vary and that no results can be guaranteed.
4. I understand that hypnosis / hypnotherapy is not a replacement for medical treatment or psychiatric services.
5. I have been informed as to the scope of treatment that will be provided to me.
6. I have been informed that hypnosis / hypnotherapy is a collaborative process, and the degree of progress is dependent on my active participation and engagement throughout the process.
7. I declare that, if advised prior to my hypnosis / hynotherapy sessions to seek medical approval, I have consulted with my general practitioner and any other medical professional to gain the appropriate medical approval.
8. I understand that in some cases, it may be necessary for the practitioner to respectfully touch my shoulder(s), hand or wrist to assist me in attaining or returning from a hypnotic state. I give permission and consent to do so.
9. I understand that hypnosis / hynotherapy may bring up painful feelings, thoughts, images, or memories.
10. I have accurately provided background information as requested.
11. I agree to the number of sessions that were discussed with me.
12. I agree to pay for any session prior to it taking place.
13. I have been advised that I am free to terminate any or all sessions at any time.
14. I agree to participate in each session to the best of my ability.
15. I agree that contact between sessions will be strictly limited to telephone, email, or letter.
Confidentiality
Communication between you and your practitioner is confidential. This means that your case will not be discussed orally or in writing without your expressed written permission. Your practitioner has an ethical and legal obligation to break confidentiality under the following circumstances:
a) If there is a reason to believe there is an occurrence of child, elder, or dependent adult abuse or neglect.
b) If there is reason to believe that you have serious intent to harm yourself, someone else, or property by a violent act you may commit.
c) If you disclose that you knowingly develop, duplicate, print, down-load, stream, or access through any electronic or digital media or exchanges, a film, photograph, video in which a child is engaged in an act of obscene sexual conduct.
d) If you introduce your emotional condition into a legal proceeding.
e) If there is a court order for release of your records.
I agree to the above stated terms and give my full consent to receive hypnosis/ hynotherapy services: