Thank you for your payment. Your transaction has been completed, and a receipt for your purchase has been emailed to you. Please complete and submit the document below to confirm your appointment with Self Image Studio.SELF IMAGE STUDIOHypnotherapy & RTT Terms and Conditions Hypnotherapy(HT) & Rapid Transformational Therapy(RTT) are unique methods to resolve most deeply rooted issues. HT/RTT uses hypnosis which is a completely safe, natural, and relaxing process where you will remain in control throughout the duration of your session. During HT/RTT you will be regressed back to several memories in order to uncover where, when, how, and why you developed your presenting issue/ problem. This insight will help you to gain a deeper understanding of the root, the cause, and the reason for your problem/ issue. Please understand that you play an active role in the successful outcome of your session(s). You must be motivated to change and follow through with the process. HT/RTT is not meant to be a substitute for the advice or care of a qualified medical professional. All information presented or recommended by Gabriella Phillips is meant for educational purposes only. If you are unsure about whether or not you should partake in an HT/RTT session, please consult your general practitioner first. To protect your privacy, all client data is kept strictly confidential. Liability I,* First Last hereby release, Gabriella Phillips, Certified Hypnotherapist, from any liability or claims that could be made against her concerning my mental and/ or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form. Scope of Practice I understand that Gabriella Phillips is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnotherapy should not be considered a replacement for the advice and/ or services, of a psychiatrist, psychologist, psychotherapist, or doctor. In recognition that millions of Californians receive a substantial volume of healthcare services from complementary and alternative health care practitioners, California Law allows access by California residents to complementary and alternative healthcare practitioners who are not providing services that require medical training and credentials. The following disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code. The purpose of a program of hypnotherapy is for vocational and avocational self-improvement (California Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state. A hypnotherapist is not a licensed physician or psychologist and hypnotherapy services are not licensed by the State of California. Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures. Hypnosis works with the power of the subconscious mind to change habits and behaviors. The subconscious mind is considered to be the source or root of many of our behaviors, emotions, attitudes, and motivations. Hypnosis is believed to be a powerful tool for accessing the subconscious mind and creating improvements in our lives. Services consist of a program of conditioning, including an undetermined number of private sessions, depending on the client's individual needs. Gabriella Phillips, Certified Hypnotherapist, will to the best of her ability, endeavor to accomplish the objectives of the clients sessions. While hypnosis may be an effective technique for a variety of different purposes, the efficacy may vary from individual to individual. No specific outcome, result, or progress can be promised or guaranteed. During hypnotherapy sessions, clients remain completely aware of everything that is going on. Many people experience a hyper-awareness where sensations are perceived, enriched, and vivid. The ability to visualize or imagine is enhanced. Deep relaxation is common. Many describe the hypnotic state as a complete and total escape from physical tension and emotional stress, while remaining completely alert. The use of hypnosis may elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis may be distorted or misconstrued. Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client. While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in therapy. I understand the information described above. I also understand and agree that the main purpose of this program is for Vocational or Avocational Self-Improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professions Code 2908). Participation I give Gabriella Phillips full permission to hypnotize me and to use Rapid Transformational Therapy knowing that by participating fully in the process and by listening to my personalized audio recording for a minimum of 21 days, I play an important role in my overall success. Guarantee I understand that although Hypnotherapy & Rapid Transformational Therapy have an incredibly high success rate, Gabriella Phillips cannot and does not guarantee results since my own personal success depends on many factors that Gabriella Phillips has no control over, including my willingness and desire to affect the changes inside of myself. Audio Recording(s) I give Gabriella Phillips full permission to make audio recordings that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s), Gabriella Phillips retains full copyright over any forms of media that may be produced and distributed to me. Deepening Process I hereby grant permission to Gabriella Phillips to respectfully lift my arm, touch my shoulder, tap my forehead, or rock my head during my Rapid Transformational session(s) in order to help facilitate the deepening process. Confidentiality By signing this form, I consent that Gabriella Phillips may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; If I as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested. I also understand that , at any time, Gabriella Phillips may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise. Pertinent Details Before taking part in your HT/RTT session(s), please ensure the following: 1. That you do not suffer from epilepsy. 2. That you will be free from the influence of drugs or alcohol during the course of your session. 3. That you provide me with the correct email address of your online location. 4. For online/ skype/ zoom sessions, that the environment around you is safe and will remain distraction free. In addition, please ensure that you provide me with a phone number or other means of communication to contact you with in the case of a technology failure. 5. That you provide me with a third-party emergency contact number. 6. I understand that we uphold a strict cancellation policy and we require a 48 hour cancellation request in writing via email in order for payment to be refunded. Cancellation email must be sent to Gabriella@SelfImageStudio.com at least 48 hours prior to confirmed appointment time. I confirm that I have read and accept the following terms and conditions.Name* First Last Date of Birth* Address*City, State, CountryEmail* Phone*Age*Please enter a value greater than or equal to 18.Martial Status*Occupation*Name of DoctorDoctor PhoneDoctor AddressLast Check Up Medication being taken*Emergency Contact*Emergency Contact Phone*Signature*Please sign above using your mouseToday's Date* If under the age of 18, Please enter Guardian's detailsName of Guardian First Last Guardian's AddressGuardian Email Guardian's PhoneGuardian's SignaturePlease sign above using your mouseToday's Date This iframe contains the logic required to handle Ajax powered Gravity Forms.
