THE PATHWAY HYPNOTHERAPY ROOMS

Confidential

Client Information

Address

Occupation

What is your primary reason or desired outcome for today’s visit?

Below is a list of common concerns that lead people to seek professional assistance. Please check all that apply to you.

Anxiety/StressGeneral FearsSmokingInsomniaFear of Public SpeakingSports PerformanceChronic PainLack of MotivationAlcohol/Drug UseDepressionLow Self EsteemTest AnxietyWeight IssuesPhobic ReactionsUnwanted HabitsSurgical AnxietyRelationship IssuesGoal Setting

How did you learn of The Pathway Hypnotherapy Rooms?

What do you want to change?

Please ensure that you take the time to read this contract carefully before signing.

Name of Client

Remedial Hypnotist Agreement

I hereby agree to provide hypnosis session/s to

in order to help with

issue

I agree to treat all Clients in an ethical manner and use my training and experience in the best way possible in order to help you to overcome your issues. I will conduct our sessions in areas in which I am competent. My sessions will always be aimed at promoting your well-being and maintaining respect and dignity for you the client. I will abide by the Code of Ethics of The National Hypnotherapy Society.

The number of sessions will be determined by your progress and by mutual consent.

Confidentiality: Our sessions are confidential within the client/therapist relationship, and I will not release any information to anyone without written authorization from you unless I believe that there is a safeguarding issue to myself, you the client, members of your family or members of the public nor in contravention of any legal action (i.e. criminal, coroner or civil court cases where a court order is made demanding disclosure) or legal requirement (e.g. Children’s Acts.)

Confidentiality is very important to me. Therefore, your details will always be kept secure. However, your notes may be shared at times with my supervisor. All personal details will be anonymized.

By signing this contract, you are agreeing to your notes being shared as described above.

Data Protection Statement: All personal data collected by The Pathway Hypnotherapy Rooms will only be used in conjunction aimed at promoting your well-being. All client notes and records are kept secure and confidential and the use of computer records remains within the terms of the Data Protection Act. All manual records will be kept locked away when not in use and those held on computers will always be password protected.

Qualifications: I am fully qualified as a Hypnotist and I am a member of The National Hypnotherapy Society that holds the first and only current hypnotherapy register to accredited by the Professional Standards Authority under its Accredited Registers programme. An Accredited Register is the result of the programme set up by the Department of Health and administered by the Professional Standards Authority who are an independent body, accountable to Parliament.

I am a registrant member of The National Hypnotherapy Society and agree to provide their contact details if you see a reason to bring about any complaint against me.

Contact between sessions: If there is an urgent need to speak to me please contact the number above and I will contact you at my earliest convenience. If our paths should cross outside of our sessions then, I will not acknowledge you as in doing so will be in breach of our confidentiality agreement.

Notice: Hypnosis focuses on your imagination and subconscious to help bring about positive changes to your thoughts or behavior. Together I and you will decide on the desired changes to work on prior to the hypnosis occurring. Hypnosis is not the practice of medicine or psychotherapy. If you have an ongoing medical illness, mental disability or mental illness, please consult a medical doctor, psychiatrist or psychologist licensed by The General Medical Council.

Client Agreement

The service fees and payment schedule for your programme of sessions will be confirmed within your consultation confirmation letter.

Visa, MasterCard. Bank Transfer & cash are all acceptable forms of payment.

Our sessions are very important and therefore it is necessary for you to attend all pre-booked ones. However, if in the likely hood that you are unable to attend then please inform me at your earliest convenience so that we can rebook another appointment as quickly as possible which will ensure that we continue with your treatment course minus further delays.

Any cancellation for which less than 48 hours’ notice has been given shall be charged the full session fee.

If I decide to cancel all future agreed sessions, I will notify The Pathway Hypnotherapy Rooms one week in advance.

I acknowledge that in order to be successful in the change I want, I must accept that the following tenets are important to the process:

• I understand that my health and well-being depend on how well I care for myself physically, emotionally, intellectually and spiritually.
• I accept that my thoughts, feelings, and desires directly determine the course of my life and my relationships.
• I recognize that blaming myself or others serves no purpose.
• I acknowledge that I am responsible for my experience of life as I make the choices and take the actions which shape my life.
• I agree to be an active participant in my hypnotherapy process and see myself as an equal partner in the success of the process. I can demonstrate this by being on time for my sessions and being fully present.

My Commitment to You

I agree to use my abilities and expertise to facilitate such changes as are mutually agreed to be in your best interest. I will offer you my undivided attention during our scheduled sessions. I am professionally committed to assisting you in using your inner resources to achieve your desired outcomes in the shortest possible time.

I agree that there is no guarantee that my problem will be ‘cured’.

Date

Client Sign