California Disclosure Form

Sample form

New Client Information

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

Name of hypnotherapist (hereafter referred to as “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 feelings and to transform undesirable habits and behavior 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. The Legislature finds that these non-medical complementary and alternative services do not pose a known risk to the health and safety of California residents, and that restricting access to those services due to technical violations of the Medical Practice Act is not warranted. Accordingly, Hypnotherapists are not issued licenses by any State Governmental Agency to engage in their professional services.

I understand that these sessions are not psychotherapy but are a therapeutic alternative aimed at creating positive changes in my life. I agree to inform my hypnotherapist of all physical or mental conditions that might affect her work with me. I understand that I am a full partner in creating changes and am willing to participate during my sessions and to complete any home assignments.

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