Disclosure Form

Here is the ACHE’s recommended disclosure form for California hypnotherapists. Beginning January 1, 2005 this form will become mandatory for all ACHE certified Hypnotherapists.

CLIENT INFORMATION

The undersigned Client acknowledges that he or she has been informed of the following information:

Hypnotherapist agrees to provide professional services in accordance with acquired training and experience giving undivided attention during scheduled consultations to facilitate Client’s benefits. Hypnotherapist’s work is Client-centered. Services provided utilize induction of hypnosis, and methods and principles used to help clients discover their inner creative abilities to develop positive thinking and feeling and to transform undesirable habits and behaviour patterns. Therapeutic goals are to achieve freedom from restrictive thought and belief systems, to assist in solving personal problems, developing motivation and achieving goals. Client may be taught the use of self-hypnotic techniques to assist in achieving goals and resolving issues that have been mutually agreed upon by Client and Hypnotherapist.

Hypnosis is not a state of sleep, but is a natural state of mind that can produce extraordinary levels of relaxation of mind, body and emotions. The principles and theories upon which hypnotherapy is based are accessing and utilizing the power of one’s inner resources. Hypnosis can transcend the critical, analytical level of mind, and facilitate the acceptance of suggestions, directions and instructions desired by the Client. The therapeutic use of Hypnosis can also elicit information and insights from the inner mind. The hypnotherapist utilizes interviews, discussion and hypnotic methods dealing with underlying issues whenever appropriate, with the goal to achieve effective and lasting results.

Services to be provided do not include the practice of medicine, as Hypnotherapist is not a licensed physician. These services are non-diagnostic, and are complementary to the healing arts services that are licensed by the state. The California State Legislature has determined that state licensing may not be conferred upon an occupational group for purposes of status or prestige. The primary purpose of licensing laws for legally defined Healing Arts and Mental Health professionals is to protect public health and safety. Accordingly, Hypnotherapists are not issued licenses by any State Governmental Agency to engage in their professional services.

I, _____________________________, have acquired the following education, training, experience, and qualifications to perform the services offered to my Clients:

See the affixed document labeled “Attachment A” (or provide within this paragraph)

For complaints not resolved by Hypnotherapist, contact the American Council of Hypnotist Examiners,
3435 Camino del Rio S, Ste. 316, San Diego, CA 92108.

I, the undersigned Client acknowledge that I have been advised of the foregoing information, and that I have been given a copy of this “New Client Information” form.

________________________________ Dated: ________________________ Client’s Signature