Covid-19 Hypnotherapy Session Intake and Consent

Covid-19 Hypnotherapy Session Intake and Consent Form

Please note, if you have any of the above conditions, we must have a doctor's written referral to proceed with your hypnotherapy session.

Informed consent
  • I understand that hypnosis is a method for self-exploration and/or behavioral change. This may enable tme to search for meaning and understanding and to direct my own personal growth and development. I further understand that all hypnosis is self-hypnosis.
  • Since I am in total control of the hypnotic state and session, I can stop a session at any time.  The facilitator will use symbols and symbolic language, which I will interpret according to my own belief system. I understand that hypnotherapy uses trance and suggestion to adjust habits of thought, feeling and behaviour. 
  • I choose the goals for hypnotherapy.  I also choose the topics of discussion while in the trance state.  I understand that hypnotherapy is not offered as substitute for medical diagnosis and care.
  • I agree to allow my sessions to be recorded (audio only) for my personal record. I will receieve a copy of these recordings.  I understand that all information on this form and from any hypnotherapy sessions is strictly confidential.
  • I enter into hypnotherapy willingly and out of my own desire for self-exploration and/or behavioral change.  Furthermore, I certify that I am requesting hypnotherapy services on my own initiative and realize that (practitioner) does not diagnose ailments or prescribe treatment.
Enter the date and your full name to acknowledge your electronic signature of this document.
Your Electronic Signature*