I, the undersigned, understand and agree to the following:

I agree to pay Lisa Percival, C.Ht., a fee of __________ per session, in full for services rendered, on the date of each session.

I agree to give 24 hours’ notice on all cancellations or changes of scheduled appointments. I understand that missing a scheduled appointment without prior cancellation may incur a charge at the full rate.

I understand that the program of conditioning offered to me will include an undetermined number of private sessions, depending upon my individual needs. I understand that the primary purpose of this program is for vocational and avocational self-improvement and those problems of psychogenic or functional origin are treated under the supervision of psychological or medical referrals only (Business and Professional Code 2908). I also understand that there are no guarantees as to the progress to be realized, only that the best effort will be made to accomplish the objective of my sessions.

Additional conditions:

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Client                          Date              Hypnotherapist                Date

DISCLOSURE OF SERVICES

 In recognition that millions of Californians receive a substantial volume of health care services from complementary and alternative health care practitioners, California Law allows access by California residents to complementary and alternative health care practitioners who are not providing services that require medical training and credentials. The following disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code.

The purpose of a program hypnotherapy is for vocational and avocational self-improvement (Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state. A hypnotherapist is not a licensed physician or psychologist and hypnotherapy services are not licensed by the state of California. Services are non-diagnostic and do not include the practice of medicine, nor should they be considered as a substitute for licensed medical or psychological services or procedures.

Hypnosis works with the power of the subconscious mind to change habits and behaviors. The subconscious mind is considered to be the source or root of many of our behaviors, emotions, attitudes and motivations. Hypnosis is believed to be a powerful tool for accessing the subconscious mind and creating improvements in our lives.

Services consist of a program of conditioning including an undetermined number of private sessions depending upon the client’s individual needs. The hypnotist will to the best of his or her ability endeavor to accomplish the objectives of the client’s sessions. While hypnosis may be an effective technique for may purposes, the effectiveness may vary from individual to individual and no specific results or progress can be promised or guaranteed.

During hypnotherapy sessions, clients remain completely aware of everything that is going on. In fact, many people experience a hyper-awareness there sensations are perceived enriched and vivid, The ability to visualize or imagine is enhanced. Deep relaxation is common. Many describe the hypnotic state as a complete and total escape from physical tension and emotional stress, while remaining completely alert.

The use of hypnosis could elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis will be distorted or misconstrued. Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client.

While it is the practice of hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in therapy.

I have received a copy of this disclosure and understand the information described above. I have also read on the other side of this document a biography of the hypnotherapist’s education, training, experience and other qualifications regarding the services to be provided.

Client Name: (Please print)________________________________

Client Signature:_______________________

Date:__________________________