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Distance Hypnosis Form Submittal


 Please fill out the form below entirely.

If a field is skipped that is mandatory then you will be asked to fill it in before proceeding.
 

 

 

Client History, Consent, & Contract Agreement Form

F.Name: L.Name:
Phone: Email:
Street: City:
State: Zip:
Age:    

Reason you are coming for hypnosis?

Are you currently receiving medical treatment for the above problem?  Yes   No

Are you currently receiving mental health treatment for this problem?  Yes   No

If yes - Psychiatrist/Psychologist/Counselor's Information

Name:    
Phone:      (Please include area code)

Primary Prescribing Doctor’s

Name:  
Phone:    (Please include area code)
Fax:  (Please include area code)

Have you been treated for or currently have problems with?   Heart   Diabetes   Epilepsy

How did you hear about us?



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 Client Bill Of Rights
Tim Bartley CHt
Renaissance Alternative Health Center
 734-418-0036
www.ThoughtBecomesReality.com
 TimB@ThoughtBecomesReality.com
 

I, Tim Bartley CH, am a trained and certified hypnotist by The Omni Hypnosis Training Center with director Gerald F. Kein, (8/3/2005).  I have established a private practice and my active business name is Renaissance Alternative Health Center.  I have thus far conducted thousands of private professional sessions, group seminars, authored a book on hypnotherapy and continue my education in my profession. 

Theta State Therapy (TST)  This therapy term is coined by me and is conceptualized from a combination of hypnotherapy, NLP (Neuro-Linguistic Programming), and psychology techniques.  It is a series of conversations between myself and my client.  It is based on the theta brain wave state, relaxation, imagery, memory, and emotion to elicit permanent change for emotional, habitual, and physical problems. 

Hypnotism is a self-regulating profession of certified practitioners.  It is not at this time licensed by state governments.  I am neither a physician nor a licensed health care provider and I do not provide medical diagnosis or medical treatment for illness, disease, or mental disorders.  My treatment methods do not replace conventional medical procedures but works in conjunction with the medical health care system. 

ALL INFORMATION IS STRICTLY CONFIDENTIAL.  I will not release any information to any person without a written authorization from you, except as provided by law.  You have the right to be allowed access to all my written records pertaining to you. 

I agree to work with, Tim Bartley CH, for the purpose that is described.  I fully understand that hypnotherapy/TST is a mental conditioning process that will allow me to use the natural faculties of my mind to create desired and positive change and health in my life.  I understand this approach is complementary to, and not a substitute for medical care by a physician.  I therefore release Tim Bartley from all medical liability.

 

Submission of this form verifies that I have read this
Client Bill of Rights and I understand what I have read.

ALL INFORMATION IS STRICTLY CONFIDENTIAL

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Please Read

Fee Additions & Adjustments

- Being on time & “No shows” (absenteeism)

          o We require 48 hour notice for cancellation & rescheduling.

          o We book up to five sessions per day, being late or “no shows” greatly affects our office &
             other clients.

You will be charged for the session if you attend or not without 48 hours notice.

If you are 15 minutes or more late we reserve the right to not hold the session & charge $25.
(This offsets our entire schedule for all clients coming in after you)

If two appointments are missed without 48 hour notice or you are 15 minutes late twice or more or you cancel/reschedule multiple appointments Renaissance can, at its discretion, permanently refuse services. This however does not absolve you of agreed upon fees as stated in this contract.

- All subjects do not follow directions, or think through the process. If this occurs a $35 fee is charged for the attempted session and we will wave the regular per session fee or program fee until the time where we are able to proceed without these issues. This is solely determined by Renaissance Alt. Health Center. (A conditioning audio CD will be provided to you at no cost.)

- We do not issue refunds under any circumstances. Once I enter into this contract I am bound to its terms and must pay for the program/session in full. I agree to pay court costs and attorney fees if I am late in paying for or do not pay for said treatment and Renaissance deems collection procedures are necessary.

Note***
  If you are currently taking medication we would ask that you abstain from taking medication 24 hours before our sessions if possible. Do NOT stop taking your medication without first speaking with your doctor.  If you wear contact lens or glasses please remove them before our session.
 

  By clicking on the submit button below I understand that I am legally giving my consent to all of the provisions of this, (Client History, Consent, & Contract Agreement) form.

(Submission of this form acts as your legal signature)