HCH Institute

There are potential benefits and risks of video-conferencing limits to client confidentiality) that differ from in-person sessions. *

• Confidentiality still applies for on line services, and nobody will record the session without the permission from both the client and therapist. • We agree to use the video-conferencing Zoom platform selected for our virtual sessions, and the therapist will explain how to use it. • You need to use a computer, or smartphone during the session. • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. • It is important to use a secure internet connection rather than public/free Wi-Fi. • It is important to be on time. If you need to cancel or change your online appointment, you must notify the therapist in advance by phone or email. • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. • If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in the online sessions. • You are responsible for full payment. Payments are made through the PayPal site. Use this email for payment: holly@hypnotherapytraining.com

I Have Read, Understand and Accept This Disclosure

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The following disclosure is intended to fulfill the requirements of the California Senate Bill #SB577, passed in September 2002, affecting all non-licensed helping professionals offering alternative health care. *

1. HCH Clinical Hypnotherapist Interns, Reiki Practitioners, Energy therapists and Shamanic Practitioners are not licensed physicians or psychotherapists. They are not qualified to diagnose, treat or prescribe for physical or mental conditions. 2. The use of Hypnotherapy, Reiki, and Shamanic Practices is alternative and complementary to healing arts services licensed by the State of California. 3. The services offered in the HCH Low Fee Community Clinic are not licensed by the State of California but the training HCH Interns have received has been approved by the International Board of Regression Therapy, The Professional Board of Hypnotherapy, the California Board of Registered Nurses and the California Association for Marriage Family Therapists. 4. Services offered include Hypnotherapy, Reiki, Emotional Freedom Technique (EFT) and Shamanic Practices, for the purpose of pain management, goal setting, performance enhancement, self-healing, regressing therapy, spiritual emergence issues, trauma, relationship issues, learning enhancement, stress management, career issues, exploring life purpose, personal growth and discovery. None of these services is intended to be a substitute for medical or psychological care. Any issue beyond the scope of the HCH Intern’s training and practice will be referred to a licensed practitioner. 5. It is the goal of HCH and all HCH Interns to provide clients with a safe, non-judgmental and supportive environment where clients can gain insights into established patterns of behaviors and work towards transformation and personal growth. Because all of the services and modalities are based on the empowerment model, all clients do their own works and healing with the guidance of a co-creative facilitator. 6. All HCH Interns have completed the HCH Board approved 200 hour training in Hypnotherapy and are Certified Hypnotherapists. 7. All are trained in EFT. Many of the Interns are also trained in Reiki, Shamanic Practices and other Energy Therapy Modalities. All Interns are currently enrolled in a 100-hour, six-month, Clinical Internship Training which will result in a Clinical Hypnotherapist Certification. I have read and understand the disclosure.

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HCH Interns observe professional standards with regard to confidentiality *

Interns will not reveal information disclosed in the course of any meeting unless required to by California reporting codes. Services at HCH, Institute for Hypnotherapy and Psychospiritual Trainings, are provided by Certified Hypnotherapists who are continuing in advanced post-graduate clinical training through the Low-Fee Community Clinic. As a part of this training meetings with you may be discussed in supervision for educational and training purposes. Your name will remain confidential. Please complete the following: I give my certified hypnotherapist, permission to audio or video tape my meetings for the purpose of supervision. (Initial whichever applies.) I understand the fee for each one hour meeting is $40.00 or 4 sessions for $140.00 to be paid at the end of each meeting by either cash, check, or Visa/MasterCard . I understand that there is a 24-hour cancellation requirement for any follow-up meetings. I understand that I will be billed full fee for a missed appointment.

I have read and understand this disclosure.

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