I hereby consent to the modalities of hypnosis, life & mindset coaching, NLP and/or Rapid Resolution Therapy® (RRT), by an Energy Medicine Practitioner (EMP)/coach and Certified Professional Hypnotist which may include but is not limited to: life coaching, NLP techniques, guided visualizations, hypnotic healing and other modalities aligned with life coaching, hypnosis, RRT and/or NLP and within the scope of practice as an Energy Medicine Practitioner (EMP), Life Coach, NLP Practitioner & RRT Facilitator. I will immediately notify my coach/EMP of any unanticipated or unpleasant effects associated with any of the modalities applied.

• I understand that these services are consultative in nature and do not substitute formal psychotherapy and/or diagnostic services. In the event that a referral is needed for on-going psychotherapy, one will be provided at your request! I further understand that life coaching is a separate form of help that is not considered therapy or counseling.

• I do not expect my coach to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the coach/practitioner to exercise judgment during the course of treatment which the facilitator/coach exercises a best and highest interest for healing, based upon the facts then known and for my best interest and highest good. I understand that results are not guaranteed.

• I understand that all clinical information and records of coaching/NLP & RRT modalities etc. will be kept confidential and will not be released without my written consent.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of hypnosis, life coaching, NLP and RRT and have had an opportunity to ask questions. I intend this consent form to cover the entire course of my sessions for my present life issues/stressors and for any future conditions(s) for which I seek coaching modalities.

APPOINTMENTS AND CANCELLATIONS

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours. The standard meeting time may vary depending on the modalities being implemented. It is up to you, however, to determine the length of time of your sessions. Requests to change a session meeting time allotment needs to be discussed with the practitioner in order for time to be scheduled in advance. A $10.00 service charge will be charged for any checks returned for any reason for special handling.

Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

TELEPHONE ACCESSIBILITY

If you need to contact me between sessions, please leave a message on my voice mail or text me. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that while face- to-face sessions are highly preferable to virtual sessions, only virtual sessions are being considered at this time due to Covid-19. If a true emergency situation arises, please call 911 or any local emergency room.

ELECTRONIC COMMUNICATION

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss confidential content and/or request assistance for emergencies. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your energetic practitioner chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to treatment, better continuity of care, and reduction of lost work time and travel costs.