Waiver
Liability
I, _________________________, Hereby release Kelli Nordhus 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 kellinordhus is not an MD or psychologist and that hypnosis should not be considered a replacement for the advice and/or services, as a psychiatrist, psychologist, psychotherapist, or medical doctor.
Participation
I give Kelli Nordhus full permission to hypnotize me knowing that by participating fully in the process and by listening to my personalized recording for 21 days, (if applicable) I play an important role in my overall success.
Guarantee
I understand that although hypnotherapy has an incredibly high success rate, Kelli Nordhus cannot and does not guarantee results since my own personal success depends on so many factors that Kelli Nordhus has no control over, including my willingness and desire to affect the changes inside of myself.
Audio recording
If we’ve discussed this and I would like to have a recording of my session, I give Kelli Nordhus permission to make an audio recording, that may include my voice. I understand that if a recording is made during or after my session Kelli Nordhus retains full copyright over any forms of media that may be produced and distributed to me.
Deepening process
If done in person, I hereby grant permission to Kelli Nordhus to respectfully lift my arm, touch my shoulder, forehead, or rock my head during my hypnotherapy session in order to help facilitate the deepening process.
Confidentiality
By signing this form, I consent that Kelli Nordhus may release information to a specific individual or agency if it has been determined that a child or elder is at risk of, are currently being abused. If I, as a client, am in eminent danger to myself or others, or if a subpoena of records have been requested. I also understand that, at any time, Kelli Nordhus may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise.
I understand if I am epileptic or suffer from psychotic illness it is not generally recommended that I undergo hypnotherapy I hear by agree that by booking and paying for Kelli Nordhus’s services that I do not currently suffer from these disorders.
Please read the above - then agree to the terms by typing your name and date below. Thank you.
________________________________________
