I freely consent to provision of services
by Hypnosis for Life Inc. and Terri Cooper RSW NLP-M DCH and such techniques or
procedures in the course of the services that may be deemed advisable by
Hypnosis for Life Inc. and Terri Cooper.
I understand that Terri Cooper is a registered social worker who employs the modalities of hypnosis; conversational hypnosis, clinical hypnotherapy, neuro linguistic programming and solution focused coaching under the umbrella of Hypnosis for Life Inc.
I understand that service is being provided
from the moment my appointment time begins. I understand that there is an
educational, experiential learning component to the work and that ultimately I
am responsible for utilizing the tools offered. I understand that “quick fix”
hypnosis is for entertainment and that all lasting change requires my personal
I understand that hypnosis is a natural
state of mind that can produce relaxation of mind and body and that focused
concentration is required. I understand that moving into hypnosis is a learned
skill for many people. I take full
responsibility for my ability to move into hypnosis although I understand that
I will be supported to do so in my session. I understand that it is my
responsibility to make use of and practice any follow up tools I am offered.
I am aware that services are not offered as
a substitute or replacement for conventional medical or psychological care. I
understand that hypnosis is not diagnostic and does not include the practice of
medicine. I agree that I am not seeking
hypnosis services for a diagnosed medical or mental illness.
I understand that Hypnosis for Life Inc.
records all sessions and such sessions remain the property of Hypnosis for Life
Inc. If I purchase or am offered a copy of any media files for the purpose of
ongoing programming, I understand that I cannot mass broadcast, share or
reproduce these files. I understand that
I must obtain written permission from Hypnosis for Life Inc. to record sessions
as propriety system is being used.
I understand the Hypnosis for Life Inc. has
an ethical obligation to keep confidential all information received as per
provincial legislation, which allow for exceptions.
I understand that Hypnosis for Life Inc is
not a charity or a funded government organization but a specialized private
practice and that session fees are paid at time of scheduling. Personal medical
emergencies, supported by a doctor’s note, allow for rescheduling (versus
cancellation) of the appointment. This policy was explained to me during
scheduling and reiterated in confirmation email I received.
At no time has a “guaranteed quick fix” one
session solution been offered to me. I
realize that creating realistic change requires my ongoing participation and
commitment. There are reasonable and responsible follow up actions available to
me: listening to individual sessions via mp3
which can be purchased, attending further individual sessions
which may or may not be shorter in duration or attending group training sessions.
I have read and understood this document.
And I hereby release Hypnosis for Life Inc and Terri Cooper personally and all
other organization or companies affiliated or owned by Terri Cooper or under
the umbrella of Hypnosis for Life, its assistants, employees and agents. Of any liability for injury,
loss or damage incurred during any and all sessions, regardless of whether such
loss and damages is incurred through the negligence or fault of Hypnosis for
Life Inc, Terri Cooper or its assistance,
employees, or other agents. By my selection of “yes” I confirm my consent to