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Disclosure Form
The undersigned client acknowledges that he or she has been informed of the following information:

Linda Simmon (hereafter "Hypnotherapist") agrees to provide professional services in accordance with acquired training and experience to facilitate Client's benefits. Hypnotherapist's work is client-centered. Services provided utilize induction of hypnosis and methods and principles used to help clients discover their inner creative abilities to develop positive thinking and feeling and to transform undesirable habits and behavior patterns. Therapeutic goals are to achieve freedom from restrictive thought and belief systems, to assist in solving personal problems, develop motivation and achieve goals. Client may be taught the use of self-hypnotic techniques to assist in achieving goals and resolving issues that have been mutually agreed upon by Client and Hypnotherapist.

Hypnosis is not a state of sleep, but is a natural state of mind that can produce extraordinary levels of relaxation of mind, body and emotions. The hypnotherapist utilizes interviews, discussion and hypnotic methods dealing with underlying issues whenever appropriate, with the goal to achieve effective and lasting results.

Services to be provided do not include the practice of medicine. Hypotherapist is not a licensed physician. These services are non-diagnostic and are complementary to the healing arts services that are licensed by the State. The California State Legislature has determined that state licensing may not be conferred upon an occupational group for purposes of status or prestige. The primary purpose of licensing laws for legally defined Healing Arts and Mental Health professionals is to protect public health and safety. Accordingly, Hypnotherapists are not issued licenses by any State Governmental Agency to engage in their professional services.

Hypnotherapist has acquired certification from The Hypnosis Motivation Institute a state licensed and accredited school with state approved hypnotherapy instructors and has the training, experience and qualifications to perform services offered to Client. A copy of Hypnotherapist's Certification Certificate is available upon request.

I, the undersigned Client acknowledge that I have been advised of the foregoing information and that I have been given a copy of this "Disclosure Form".

          ______________________                               _______________________________
                        Date                                                                Client's Signature


                                                                                _______________________________
                                                                                                   Print Name

 

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