Please Complete ALL Forms in Advance of Appointment
ACKNOWLEDGEMENT OF SERVICES AND FEES
APPLICATION, PERSONAL DATA RECORD AND RELEASE
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 of hypnotherapy is for vocational and avocational self-improvement (Business and Professions Code 2908) and as alternative or complimentary 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, neither 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 on the client’s individual needs. They hypnotist will to the best of his ability endeavor to accomplish the objectives of the client’s sessions. While hypnosis may be an effective technique for many 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 where sensations are preceived 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.
ACKNOWLEDGEMENT OF SERVICES AND FEES
I the undersigned, acknowledge that I understand and agree to the following:
I agree to pay Paul A Cartellone a fee of $100 per session. I agree to pay you, in full, for your services, on the date of each session.
I agree to give you 24 hours notice on all cancellations, or changes of scheduled appointments. I understand, that missing a scheduled appointment, without prior cancellation, or canceling with less than 24 hours notice, may be charged to me at the current full rate.
I understand that the program of conditioning offered by you will include an undetermined number of private sessions, depending on my individual needs. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only. (Business and Professional Code 2908). I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of my sessions.
APPLICATION, PERSONAL DATA RECORD AND RELEASE
To:Paul A. Cartellone, C.Ht.
