Name *
Non-Medical Nature of Treatment: I understand that neither Hypnosis, Life Coaching nor NLP are substitutes for medical attention. Counseling is not a substitute for a physician's role in monitoring and treating my medical needs. Disclaimer: I understand that no counseling methods, including Hypnosis, Life Coaching and NLP, can guarantee effectiveness. Hypnotism and Hypnotherapy are self-regulated professions and its practitioners are not licensed by state government. Confidentiality: No information will be released without written authorization from the client, except as provided by law. Payment Terms: The client agrees to pay $135 for a 60-minute session (excluding regression and smoking cessation sessions) until treatment is terminated either by client or the therapist. Session length can be from 40 minutes to 1 1/2 hours at the discretion of the therapist. Insurance: It is recommended that the client thinks of these services as something that they will be paying for personally. This protects the client’s privacy and often increases the personal value of the work completed. In general, insurance companies do not cover hypnosis related therapy, NLP or Life Coaching. Do not anticipate them to do so. A payment receipt for services is available upon request. Cancellations Policy: The client agrees to pay $135 for any missed appointments (48 hour notice required to avoid this fee). Fees may billed to the credit card on file for cient’s account. VOLUNTARY CONSENT FOR SERVICES I have read and understand the General Acceptance Form. I hereby request and consent to participate in services provided by Riverwalk Hypnosis and Wellness Center LLC, including follow-up contact to evaluate the effectiveness of the services provided.