Christin Curtis - Open that door

Client Consent Form

Client name

Last name

Practitioner name

Email

Address

Phone

Gender

Female

Male

Non - binary

Rather not say

Birthday

Day

Month

Year

Reason for sessions and what is your primary goal?

Medical history

Likes, Dislikes and phobias

The Practitioner:

Maintains high standards of professional and personal conduct.
Offers combination of Clinical Hypnotherapy/Age Regression Hypnotherapy/NLP/Life Coaching which is tailored to the individual client as it pertains solely to you.
Does NOT offer advice that is a substitute for general practitioner/medical advice or treatment.
Refers client to general practitioner or other practitioner(s) where necessary.
Respects the confidentiality of the client by using patient codes. Personal details are kept by the practitioner; in accordance with the code of conduct outlined by the ACCPH and Information Commissioner’s Office.
Information can be passed onto another practitioner with your written consent. Any information that breaches Public Interest will be disclosed. Freedom of Information Act 2000.

The Client:

Your hypnotherapy programme is recommended for a limited period of 3 months, specified by the Practitioner.
It is your responsibility to inform the GP about any hypnotherapy programme that you are following.
It is your responsibility to inform the Practitioner about any health problems, diagnoses, medication, treatment or supplements that you are taking.
You are required to take part in all sessions free from the influence of either alcohol or drugs.
Late cancellations, less than 7 days in advance, will be charged at an additional cost of £20.

I confirm I have read and understand the terms and conditions and understand there is a cancellation policy in place.

I confirm I have read and agreed these notes. I have not withheld any information which may affect the course of my treatment. I can confirm all discussions and treatment has been conducted with integrity and professionalism as stipulated by ACCPH in their appropriate standards and code of conduct. A term of business leaflet has been handed to me and all affiliations and qualifications disclosed.

I understand there are no specific guarantees on individual success of treatments. With certain treatments such as Hypnosis and NLP I understand levels of success can only be determined by my susceptibility to these treatments and therapies, and my completion of actions agreed at the sessions. I understand no responsibility or liability is accepted by Open that door - Hypnotherapy for my actions or behaviour's post sessions and when working live in the field.

I understand Open that door - Hypnotherapy have no responsibility for matters outside their direct control when completing live field assignments (EG a live flight) and my behaviour and actions are my own responsibility. The final decision to partake in any such live field work or exercise will always be mine and I confirm my understanding by signing this declaration.

I have read and understood the above terms of treatment and consent to progress with the consultation on these terms.

Signature

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