Step 1 of 7 14% Terms & Conditions NOTE: Hypnotist/Hypnotherapist/Practitioner are used interchangeably in the following document. I have been advised by Scott Sandland, C.Ht. the scope of hypnosis/hypnotherapy practice and I give my full consent to receiving hypnosis/hypnotherapy sessions Scott Sandland, C.Ht. I understand that results vary and that the above name practitioner may not guarantee results. Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Hypnotist/Hypnotherapist does not treat, prescribe for or diagnose any condition. I understand that the practitioner is a facilitator of hypnosis or hypnotherapy and is not practicing any other profession that requires a license under the laws of the State of California. I am aware and understand that in some cases it may be necessary for the practitioner to respectfully touch my shoulder(s), hand, wrist, 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. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability. I have accurately provided background information as requested by the hypnotist/hypnotherapist. I understand that confidentially regarding my sessions will be honored between Scott Sandland and me. This same confidentially is respected when working with minors under the age of eighteen. Do you understand and agree to the terms listed above?* Yes Disclosure Statement CONFIDENTIALITY 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. Any information shared is kept confidential. From time to time, I also consult with other colleagues, but in this circumstance, clients are not identified by name. Your signature below constitutes you giving permission for such consultations. CANCELLATIONS Since I have reserved our appointment time for you, it is my policy to charge for cancellations received less than 24 hours notice unless we are able to reschedule the appointment within the same week. Insurance companies generally do not reimburse for failed appointments. REPORTS AND PHONE CALLS There is no charge for brief calls. Calls lasting longer than 20 minutes will be charged to the client on a prorated basis. Reports requested by insurance companies, physicians, etc. will not be released without your permission.Do you accept the confidentiality agreement listed above?* Yes Please enter your contact information belowEmail* Age*Under 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerOccupation*Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Work NumberMobile NumberEmergency Contact Name*Emergency Contact Phone Number* Client Assessment FormPresenting Issue:When and under what cirsumstances did this issue begin?How has this effected your life?Has it ever been different?What specifically about your issue is leading you to seek help?Are you on any medication or have you ever been diagnosed with a mental illness?Please provide the name(s) and contact information of your doctor(s) and/or therapist(s)What life-style or attitude changes have been partially successful?Do you give Scott Sandland, C.Ht. Permission to contact your doctor(s) and/or therapist(s)?* Yes No What other kinds of therapies have you tried?Do you associate any of these emotions with your issue? Abandonment Boredom Fear Glamour Loneliness Relaxation Satisfaction Anger Depression Femininity Grief Loss Romance Shame Anxiety Embarrassment Frustration Happiness Masculinity Sadness Goals for TherapyWhat is your 1 month goal regarding this issue(s)?What is your 6 month goal regarding this issue(s)?What is your 1 year goal regarding this issue(s)?What is your 5 year goal regarding this issue(s)?Acceptance of Terms* * By selecting this box I am digitally signing this document and confirming that all submitted information is true to the best of my knowledge. Additional CommentsPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.