Client Intake Form

CLINICAL HYPNOTHERAPY & NLP CONSENT FORM Terms of Acceptance, Disclaimer and Liability Waiver for Riverina Mind Design. When a client seeks help, and we accept a person for such care, it is essential for both to be working towards the same objective. Each problem has specific goals. It is important that each client understands both the objective and the method that will be used to attain a successful outcome. This will prevent any confusion or disappointment. We do not offer to diagnose or treat any disease. We offer methods of restoring balance to your mind as a way of helping you achieve your goal and live the life you deserve. If you desire advice, diagnosis or treatment for anything going on in your body, we will recommend you seek the services of another health care provider specific for that need for by law a hypnotherapist may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. AGREEMENT: The following agreement is between RIVERINA MIND DESIGN (here forth known as "I/me/my/mine/our/we/us"), and you (here forth known as "client/you/your") Hypnotherapy & NLP Services: The provision of Hypnotherapy & NLP services entails the collection and recording of personal information relevant to your current situation. This information is a necessary part of your assessment and treatment protocol. ACCESS: Any information gathered, recorded, and filed is available upon request. Confidentiality: All personal information gathered during the course of Hypnotherapy & NLP shall remain confidential and secure except if: 1.It is subpoenaed by a court, or 2.Prior approval has been obtained to: Provide a written report to another professional or agency. e.g. a GP or a solicitor, or Discuss the material with another person. e.g. a parent or employer. THE INVESTMENT: Payment is due in full prior to the session. We accept cash, cheques and all cards accepted by EFTPOS. PayPal is available for if needed. Fees are subject to change at any time without notice. Also please read the Cancellation Policy and Guarantee Policy. A $50 service fee will be charged for all returned cheques. BOOKING DEPOSIT: The booking deposit is required to hold your appointment time. If your deposit is not paid, that still does not cancel your appointment. We require a minimum of 48 hours notice of cancellation. You, the client, are responsible for your time scheduled. The booking deposit is non-refundable unless the proper 48+ Hours cancellation notice is given. CANCELLATION POLICY: The appointment time reserved for you is exclusively for you. Please arrive promptly to obtain your full session. We require a 48-hours notice of cancellation. Unless cancelled with 48 hours or more notice, you are financially responsible for the time reserved. If you must cancel, or reschedule, an appointment due to an emergency, please notify us as soon as possible, we understand that ͚things͛do happen. If you do cancel with less than 48 hours notice, full payment for your next session is required before we will schedule a new session, regardless of reason. Thank you for your consideration and understanding. LATENESS POLICY: Lateness of more than 15 minutes results in cancellation of appointment, unless otherwise agreed upon. This time has been exclusively set aside especially for you and we want you to get the full benefit. Please note: arriving 10 minutes late, without your paperwork, will result in cancellation of your session, as well. (See Cancellation policy above.) If you have a recurring habit of being late to appointments then please arrive 10 minutes early to be safe. NO PHONE CALL/NO SHOW: In the event of a no call/no show situation, in addition to Cancellation/Lateness Policies, the client will be charged for the full session cost. NO FOOD OR DRINK ALLOWED, in the Clinic with the exception of water. HYGIENE: Good hygiene is a requirement of this clinic. Excessive body odour, excessive perfume and body care products with a strong scent will not be allowed in the Clinic due to possible sensitivities of clients who follow you. If you come to the session and hygiene and or odour is an issue, you agree to forfeit the session at ͚your͛expense. CELL PHONES: You are responsible for your phone. You, and anyone accompanying you, must TURN OFF your mobile phones completely before entering the clinic. If your phone rings, in the middle if the session, your session is considered complete. This clause applies to the formal hypnosis portion of your session, not the consultation. It is, however, quite rude to leave your cell phone on during our time. Advanced Hypnosis: I understand that the hypnotherapist cannot guarantee results any more than a doctor can guarantee results from a particular prescription or surgical procedure. I understand that hypnosis is not mind control, and that the hypnotherapist does NOT do anything to me while in or out of trance. I also understand no one on this planet has ever suffered adverse affects simply from being hypnotised. NLP (Neuro Linguistic Programming) : NLP is a system of working with the mind and the programming and ways in which the mind works. By working with the patterns, belief systems, and ideas the brain uses to sore and retrieve information and ways the brain uses to carry out the functions of the body, NLP is often able to quickly help you change this programming. This allows you to make changes at the unconscious level in a matter of minutes, vs. days or years with other systems. NLP only works because you choose to do it or not. NLP cannot do anything you don͛t want to be done. Client Agreement: I agree not to put myself or others in harms way. In a crisis I promise to call any one of the following: My GP, A Hospital, Emergency Services (000), Life Line (131114), Salvation Crisis Line (93312000). This Contract Agreement Indemnifies the Hypnotherapist and enforces in a legal and binding way my "Duty of Care" obligations in every respect. REFERRAL: Permission is hereby given for my details to be cross referenced, and/or discussed, with another Health Care Provider, Parent or Other person if deemed necessary. NOTICES: All notices, requests, demands, and other communications under this agreement shall be in writing and shall be deemed to have been given on the date of delivery: if delivered personally to the party to whom notice is to be given; if sent by electronic mail with a cc: to sender; if sent by fax; or on the third day after mailing by registered mail or express post. TERMINATION OF SERVICES: We reserve the right to refuse, and/or terminate, service to anyone, for any reason, at any time. CHANGE OF TERMS OF SERVICE: We reserve the right to change the terms and conditions of this agreement as needed. Use, and/or scheduling, of our services by you, after said changes, constitutes acceptance of those new terms and conditions. GUARANTEES: No guarantees as to the effectiveness of hypnosis for your particular problem are made or implied*, as it is impossible to guarantee human behaviour or compliance. Hypnosis is a tool you use to help yourself; therefore no refunds for services rendered are given. We do offer our efforts to help you to the best of our abilities and we sincerely want you to succeed! * The"Quit Cigarettes In 60 Minutes" and"Reach Your Ideal Weight" programs are guaranteed for life. A part from a $50 booking fee the follow up sessions if by the rare chance are needed the they will be of no charge apart from the booking fee. By registering as a client of RIVERINA MIND DESIGN, you are agreeing with the above terms of service as agreeable and binding. All questions regarding the therapists objectives pertaining to my care as client in this office, have been answered to my complete satisfaction. I will not hold Riverina Mind Design, Wayne Moffat, or any of his staff liable for any adverse effect on my health; nor will I hold this clinic, Wayne Moffat, or his staff liable if I choose to go against my doctor͛s medical advice. I therefore agree and accept the aforementioned types of care on this basis abiding to the Terms Of Acceptance. FEES: The investment for Clinical Hypnotherapy: the first session is $285.00 with each session there after at $185.00. The investment for the "Quit Cigarettes In 60 Minutes" program is $949.00 and Guaranteed for Life* The investment for the "Virtual Lapband" program is $1297.00 which consists of 4 sessions. I understand THIS SESSION WILL BE RECORDED (not electronically) for Riverina Mind Design client files and kept in strict confidence. Again, we do not diagnose or treat. We do not want to replace your medical doctor or alternative medical treatments.