Intake Form - Sensorium Hypnosis, LLC

Name *

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Today's Date *

Phone Number *

Email *

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How did you find Sensorium Hypnosis? *

If this was a referral, may I ask who referred you, so I may personally thank them?

Is it ok to communicate via text?

Best hours to reach: (copy) *

Best days/times for sessions: *

Treatment Goals: *

Are you currently involved in a lawsuit where hypnosis records may be needed?

Practitioner Education & Training - I am a certified Hypnotist through the Nation Guild of Hypnotists. I am registered through the WA State Department of Health (HP 60638443). I have an MS in Rehabilitation Counseling and have worked in the areas of mental health and physical rehab. I do not diagnose medical or mental health conditions and therefore do not provide advice regarding prescription medications of any kind. Hypnosis and Energy work can be excellent complementary healing modalities to address emotional and/or physical components of a condition or major life transition. *

I Acknowledge

Confidentiality and Disclosure Laws - Client records are kept confidential and maintained in compliance with WA State Department of Health guidelines. However, there are a few circumstances in which client information must be shared with the appropriate authorities: If you are involved in a civil or criminal lawsuit, a judge may request records be turned over to the court; If statements are made regarding abuse or neglect of a child, elderly person or disabled person; If statements are made regarding self-harm or harm to others. *

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Payment/Refund Policies

Please check the box after each statement to indicate you understand and agree to each policy. Thank you!

Medical insurance does not cover hypnotherapy *

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For new and established clients, electronic submission of payment via Square is due within 24 hours of scheduling services to avoid cancelation. This payment, along with the completed or updated intake form, will confirm and reserve my session(s). *

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Twenty-four hours advanced notice for medical related cancelations or family emergencies must be provided to reschedule a session without financial penalty. More than one missed or rescheduled session in a consecutive weekly series is considered a substantial disruption in services and may result in discontinuation of services. *

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Services are non-refundable. *

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Non-attendance ("no-shows") for a scheduled session will result in dismissal of services. *

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Practice Policies and Protocol

A clear pattern of non-compliance or non-cooperation will result in dismissal of services. *

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Under no circumstances will this practitioner offer guidance via email or text. Matters of a personal nature will only be addressed during scheduled sessions. Please reserve texts for urgent and time sensitive matters only, for example if you are running late for a session or need to cancel due to illness or emergency, etc. Whenever possible, please refrain from texting outside standard business hours (M-F, 8am-5pm). *

I Acknowledge

Being a hypnosis client is not a passive role. Just like anything else in life, you get out of it, what you put into it. The things you do between sessions are just as important as your chair time. Integrating meditation and self-hypnosis tools into your daily practice, as well as good sleep hygiene, nutrition/hydration, exercise, and making healthier lifestyle choices will enhance outcomes, no matter what issue(s) inspired you to use hypnosis. *

I Acknowledge

Although hypnosis tends to be shorter term than many other types of interventions, it is not a quick fix. Some of the shifts and changes experienced may be immediate; others more latent or delayed. As one cannot predict the speed or magnitude of recovery, in some cases, it may be advisable to schedule further maintenance sessions. You can support the efficacy of our work together by creating and/or maintaining good working relationships with other members of your helping/healing team (i.e.: talk therapist, psychologist/psychiatrist, medical provider, naturopath, recovery community/sponsor, pastor/spiritual mentor, yogi, massage therapist, etc.). Please keep in mind that living in an emotionally or physically unhealthy environment, choosing to engage in unhealthy relationship patterns or failure to follow medical/mental health treatment plans creates additional barriers to self-healing and recovery. *

I Acknowledge

My intent is to facilitate a relationship of mutual trust, respect, and open/honest communication. The work I perform is highly intuitive, spiritual, and synergistic in nature. It is not an exact science, and at times tools and strategies need to be adjusted or additional sessions scheduled. If for whatever reason, you have concerns regarding your experiences or outcome measures during or between sessions or following the completion of our work together, please do not air them in a public social forum without first seeking resolution. Kindly reach out to me personally and allow me the opportunity to address your concerns. One of the primary goals of our work together is to facilitate high frequency, self- empowering, and solution focused thinking and behavior. This is a flexible model of care that has been created with tremendous compassion and integrity. My greatest desire is for each client to feel as if their investment of time and resources has been productive. This takes courage, a strong sense of personal responsibility and the willingness to be open, transparent, receptive and optimistic. *

I Acknowledge

I use different kinds of hypnosis depending on the client and presenting issues. At times, some of the work we do may be performed in a fully awakened state. Other times, our work will involve getting into a deeply relaxed state. Both approaches have value in helping clients identify root causes and gain clarity, releasing trauma, and integrating healthier, more self-empowering strategies into daily practice and lifestyles. *

I Acknowledge

General Overview of Practices at Sensorium Hypnosis

As a hypnosis practitioner, I am fully committed to the success of my clients. Please note I cap the number of clients I see each day and reserve up to 120 minutes per client/per session so as not to rush or interrupt this deep self-healing process and to allow time to guide each client back to a place of emotional quietude prior to leaving my space. Your cooperation in attending all scheduled services, completing recommended exercises between sessions, and showing up on time is greatly appreciated. This will help your progress tremendously and allow me to provide the best experience possible.

All initial sessions run a minimum of 90 minutes. If a client is running substantially late (more than 15 minutes), the session may be shortened by the amount of time a client is late, so as not to interrupt the flow of other scheduled sessions that day. In the event you must cancel a session due to illness or a family emergency, it is your responsibility to reschedule the missed session for the next earliest feasible date. Any sessions missed during a consecutive weekly series may negatively impact or delay the progress and/or outcome of our work. Session days/times may fluctuate depending on the season/demand for services. Typically, sessions are offered Monday-Fridays from 8am-5:00pm with extended evening hours Tues-Thursday (latest session offered at 6:30pm). It is a good idea to store my cell number in your phone should you need to notify me of a late arrival or emergency cancelation of a session.

This practitioner may integrate additional tools into a client’s plan of care, such as energy and spiritual work, to promote further self-healing, as appropriate. This practitioner, however, is not advocating or endorsing any specific religious ideology, doctrine, creed, etc. All tools and strategies used are safe for clients of all beliefs and backgrounds. If you have experienced any form of religious trauma that continues to impact your life, please communicate this so I may exercise the greatest level of sensitivity regarding potential triggers. Also, if your religious beliefs create concerns regarding this modality, please let me know in advance, so we may talk this through prior to the start of services. Failure to resolve such matters beforehand may create unnecessary subconscious resistance to this intervention. Please keep in mind, hypnosis has been endorsed by the American Medical Association, the American Psychological Association, and the British Psychological Society.

The practice of hypnosis, along with other integrated modalities, may involve light touch of head, hands/arms, feet, etc. If a client is uncomfortable with this, due to past trauma or for any other reason, it is the client’s responsibility to communicate this to the practitioner who will modify her techniques.

For the purposes of privacy, confidentiality and focus, no other person, including minors, may be present during a client’s sessions. The recording of sessions is not permitted; however, guided meditations and supplementary tools will be provided to clients to reinforce the efficacy of our work together.

A hypnotherapist does not diagnose or treat psychiatric disorders and therefore does not offer any advice/opinions regarding psychotherapy services, psychotropic medication management or any other mental health related service. It is the responsibility of the client to advise any other mental health practitioners of his/her participation in hypnotherapy services, as appropriate. A client must sign a release of information, if s/he would like any other health & wellness practitioner to be able to discuss his/her case.

Hypnotherapy is not a crisis-oriented service; therefore, if a client is feeling suicidal or unsafe in any way, s/he should call “911” or check in to an emergency medical center for further evaluation. Please do not text personal details or provide sensitive information in an email.

If you are actively using recreational drugs and/or alcohol and struggling with addictions, please note this is not the appropriate venue to get clean & sober. It is highly recommended you research in-patient and/or out-patient treatment facilities, Drug & Alcohol Counseling, and participate in an addictions group, such as NA and AA. Hypnosis can however be helpful as a supporting tool after a client has experienced 6 or more months of sobriety as long as clients remain active in their recovery programs. As always, this modality, should be regarded and utilized ONLY as a complementary tool to assist in your self-healing journey, and not as a primary vehicle for drug or alcohol cessation.

Please note this is a drug and alcohol-free space. Attending sessions under the influence of any substances, including marijuana, is not permitted. If you have a medical condition and a licensed medical practitioner has prescribed marijuana as a treatment, it is your responsibility to disclose this to the hypnotherapist. Such substances may negatively impact your ability to focus and retain information, as well as achieve desired goals and outcome measures during our work together.

I have reviewed, acknowledge and agree to comply with all disclosures contained in the General Overview of Practices.

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