1. I have been advised by Anthony M. Davis, MSCA, BCH, CTACC (Board Certified Hypnotist), of the scope of hypnosis practice and I give my full consent to receive hypnosis sessions by Anthony M. Davis in today’s or any future sessions.
2. I understand that results vary and that Anthony M. Davis may not guarantee results.
3. I understand that Hypnosis is not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Hypnotist does not treat, prescribe for or diagnose any condition. I further understand that for pain or other conditions currently under the care of a medical or mental doctor, a medical referral will be required prior to beginning a hypnosis session. The appropriate medical referral form is available on the main forms page.
4. If I am pursuing hypnosis for a minor child or a person under the age of 18-years of age, of which I am their parent or guardian, I understand that the minor must be a willing participant of hypnosis. Otherwise, their success rate could possibly be minimized if they are only being hypnotized to please someone else. If in doubt, it's best to schedule a meeting with between the minor and the hypnotist to help alleviate any concerns they have beforehand. This process can increase their expectation of success.
5. I understand that the practitioner is a facilitator of hypnosis and is not practicing any other profession that requires a license under the laws of the Commonwealth of Virginia.
6. I am aware and understand that in some cases it may be necessary for the practitioner to respectfully touch my hand, arm, shoulder or forehead in order to assist me in relaxation. I give the practitioner permission and consent to do so in order to help me establish a beneficial state of hypnosis.
7. I have been advised that I am free to terminate any or all sessions at any time and I agree to participate and follow the directions of Anthony M. Davis during each session to the best of my ability.
8. I have accurately provided background information as requested by the hypnotist.
9. I understand that confidentially regarding my sessions will be honored between Anthony M. Davis and me. This same confidentially is respected when working with minors under the age of eighteen.
10. I understand that sessions may be recorded for review and planning of future sessions and to confirm ethical practice under the National Guild of Hypnotists Code of Ethics.
11. I understand that, depending on the state of my mental health, in the event that psychiatric treatment may be needed it will be suggested to me and documented by Anthony M. Davis if he determines my situation to be outside the scope of a hypnosis session.
12. I understand all monies are due before each session and all pre-paid sessions must be used within 180 days of the date of initial payment.
13. I understand that if I (as a Client) suggest any behavior deemed unethical or sexual in nature, the session will be immediately terminated without refund.
14. Matters regarding your sessions will be kept confidential except in the following circumstances: You grant me specific permission to release information to a specific individual or agency; child abuse; you are an imminent danger to self or others; or in the case of the subpoena of records.
15. Any information shared is kept confidential. From time to time I also consult with other colleagues to pursue session options for your benefit, but in this circumstance clients are not identified by name. Your electronic signature below constitutes you giving permission for such consultation.
FEES AND PAYMENTS
16. The charge for General Hypnosis session is $145.00 per session (approximately 45-min to 1-hour) unless I’m running a special discount, package discount or gift certificates. Package deals usually are cheaper per session. Payment is due before each session.
CANCELLATIONS AND NO-SHOWS
17. Since I have reserved our appointment time for you, it is my policy to charge for cancellations with less than 48-hour notice or No-Shows where a client fails to arrive. I invest myself into each client which includes pre-planning, personalized session development and the time allotted for each session. For any cancellations without 48-hour notice or No-Shows, the client will forfeit the session amount paid for that session. In case pre-payment has not been made and the session(s) are booked and there is a cancellation without 48-hour notice or a No-Show, the client will be billed for the full amount of the session.
REPORTS AND PHONE CALLS
18. There is no charge for email correspondence and brief calls less than 15-minutes in length. Calls lasting longer than 15 minutes will be charged and billed to the client on a prorated basis for $1.25 per minute. Reports requested by physicians will not be released without your permission. Simple fax reports and those requiring effort of less than 15-minutes will not be billed. Reports requiring greater than 15-minutes will be billed at the normal session rate.
POTENTIAL LEGAL ISSUE
19. In many jurisdictions, courts have held that a person who has been hypnotized cannot testify in court about anything remembered during or after the hypnosis. Consequently, if I consent to hypnosis, there is a possibility that anything I remember once the hypnosis begins will not be admissible in a court of law. The only way to fully protect my potential right to testify is to forgo the use of hypnosis.
RELEASE FROM LIABILITY
20. I understand that, because of the rulings of some legal authorities, there may be limitations placed on my ability to rely on my recollections after hypnosis for purposes of litigation. For example, there is a possibility that anything I remember once hypnosis begins may not be admissible in a court of law. I acknowledge that if I have any concerns about the legal consequences of hypnosis, I should consult with my own attorney prior to the use of hypnosis. I hereby agree, freely and voluntarily to undergo hypnosis.
I agree to release and hold harmless Anthony M. Davis from any claims or liabilities arising from the use of hypnosis. I further agree to release and hold harmless Anthony M. Davis from any claims or liabilities arising from the use of or inability to use my recollections, the hypnotist’s notes, audiotapes or videotapes of hypnosis sessions, or any other limitations on my or the hypnotist’s testimony in a courtroom or forensic setting.
In consenting to hypnosis, I hereby agree that I do not have a cause of action against Anthony M. Davis based on his professional and competent use of hypnosis with me.