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WISE MIND BWRT - Disclosure and Disclaimer Form

Waiver of Liability: I (the client), agree to release Donna Bloom (the Practitioner) of any responsibility or injury occurring from my BWRT® or Hypnosis session(s).

THE PRACTITIONER, Donna Bloom, IS NEITHER A TRAINED MENTAL HEALTH NOR A MEDICAL PRACTITIONER. At no time will my Practitioner attempt to provide medical or mental health therapy. I affirm a session with Donna Bloom at Wise Mind Hypnosis/Wise Mind BWRT is appropriate for me and does not conflict with existing medical or psychiatric treatment. I agree to always seek out and follow the advice of my physician or other professional medical practitioner before considering alternative treatment. I understand that Wise Mind Hypnosis/Wise Mind BWRT may require notification to my medical staff and in some cases, agreement from my medical staff, before starting any program where the presenting symptoms may require medical intervention or partnership (examples include drug or alcohol addiction, some chronic medical conditions, and certain mental health diagnosis). I confirm that if my session involves pain management that I will consult with my Medical Doctor before making any changes to my pain management treatment, including a reduction of prescribed medications. I confirm that if I feel I no longer need a medication or treatment program that I will consult with my Medical Doctor before reducing or eliminating any prescribed activities or medications.

No warranty is given, expressed or implied, for satisfactory results from my session(s).

Investment Structure: $550 Starting Package of 2 sessions. (The first session is typically 90-minutes and the second session is 60-minutes.) Subsequent sessions are $200 and are 60-minutes. You will be given 30 days notice of any change in fees. You may pay for services by check, cash or credit card. *In general, insurance companies do not cover hypnosis or BWRT® services.

CONFIDENTIALITY: I will not release any information to anyone without written authorization from you, except as provided for by law. Sessions at Wise Mind Hypnosis for hypnosis or BWRT® are recorded, held confidentially and become the property of Wise Mind Hypnosis.

Sessions are provided by Donna Bloom, BWRT Certified Practitioner®, BCH, MBBRS • Trained in hypnosis at New York Hypnosis Training Center in Holbrook, New York, member of the National Guild of Hypnotists • Board Certified Hypnotist by National Guild of Hypnotists • Trained as Advanced 5-PATH® Certification by The Banyan Hypnosis Center • Trained as 7th Path Self-Hypnosis® Teacher by The Banyan Hypnosis Center • Trained in BWRT® by Terence Watts, MCGI; Certified in Advanced BWRT®; Registered Member of the British BrainWorking Research Society (MBBRS)

Digital Signature - By Typing in Name, you agree to all terms.*

Agreement for Success with Wise Mind Hypnosis/ Wise Mind BWRT

A personal promise and commitment from Donna Bloom, BCH, is made to every single client. Clients are expected to make a commitment to themselves, the work and attend their scheduled appointments.

During your private sessions, you will meet with Donna Bloom, a Board Certified Hypnotist and BWRT Certified Practitioner. You will also be guided through the BWRT process, personally tailored to overcome obstacles and help you achieve your goals. The first session will be between 90 minutes - 2 hours. Each subsequent session will be approximately 60 minutes in length.

“BWRT is a quick and effective way to naturally make changes, however, it is not mind-control. Because of this, we cannot guarantee results. There is always a human factor. Your success is dependent upon utilizing the skills, resources and reinforcement provided to you throughout the program. Ultimately, your success depends on you. I do guarantee and promise to provide the very best service, using current information and appropriate techniques for your situation, within the scope of practice.”

Success Agreement Appointment and Rescheduling Policy*

Rescheduling Policy: You have agreed to attend all sessions as scheduled, and if you cannot keep a scheduled appointment you agree to provide 2 Business Days notice to reschedule the appointment. If advanced notice is not given, the appointment will be considered a paid session. If you are paying by the session, your credit card on file will be charged for the missed appointment.

You will receive a confirmation email 72 hours prior to your appointment as a courtesy reminder. Please note: it will be a no-reply email. I understand Donna will NOT and CANNOT receive any replies to those emails. You must contact Donna directly to change an appointment, no exceptions or oversights.

RESULTS AGREEMENT*

Results Agreement: “By signing this, I understand that BWRT® is not meant to diagnose or treat any disease, but rather to help me achieve my goals and promote better feelings. I also realize and understand BWRT® is not a substitute for conventional medicine. By signing this, I am stating I have read this success agreement and understand my results depend on me. Therefore, results cannot be guaranteed, nor are refunds given for services rendered."

Digital Signature - By Typing in Name, you agree to all terms.*

BrainWorking Recursive Technique® (BWRT®) - Informed Consent for Treatment

BrainWorking Recursive Technique® is a neuroscience-based process that has been shown to be useful to help reduce or alleviate the symptoms, and causes of symptoms, associated with Anxiety, Phobias, PTSD, Depression, Low confidence, Low self-esteem, and many other psychological issues. It works in a unique way to ‘defuse’ the psychological triggers of the symptom pattern before they reach the part of the brain that activates the emotional responses. In this way the symptom is either alleviated or greatly reduced in severity. BWRT® mimics the way the brain and psyche acquire the difficulty in the first place and is therefore a totally natural process. The work does not require you to divulge any intimate details of your personal life or of any event that you wish to keep private that might have been the cause of your symptom. While there is not a therapy in the world that works for everybody every time, BWRT® is considered by many to be among the most reliable of psychological methodologies. BrainWorking Recursive Technique® was discovered in 2011 by Terence Watts, MCGI, a UK therapist, author and trainer in full-time private practice since 1989. After development and many practical trials with volunteers, BWRT® was taught for the first time in October 2013. One of the first students of the new technique was South African Clinical Psychologist Rafiq Lockhat whose extensive experience in the world of psychology led to him being quickly appointed as Terence’s research partner and ‘Mr BWRT South Africa.’ Terence and Rafiq continued to refine the process into the elegant system that it is today. All trainers of this relatively new model of psychopathology are selected by The Terence Watts BWRT Institute and all adhere to the same training program to ensure, as far as possible, consistency in technical expertise across the globe.

I was personally trained by Terence Watts at: The Terence Watts BWRT Institute 118 Pall Mall St. James's London SW1Y 5ED United Kingdom Registered England No 9233079

By signing below, you indicate that you understand and accept the following (presented in no particular order):

1. BWRT® is designed to help neutralize triggers for the symptom(s) you experience. 2. There are three levels of BWRT® and your practitioner will ask you some questions that will help them decide which is the most appropriate level for you. 3. There are a few conditions in which BWRT® is not a suitable therapy and when this is the case, the practitioner will advise you accordingly. 4. The number of sessions you will need vary according to several circumstances and the practitioner will advise you where possible. Many situations respond well to between one and four sessions, though some more serious issues may need more. 5. You will not have to tell the practitioner anything you would rather keep private but there are some situations when secrets might inhibit therapy. The practitioner will advise you if this is the case. 6. If your presenting problem could be caused by a medical or physiological condition, you will need to have had a medical consultation before working with BWRT®. 7. Straightforward issues such as smoking cessation, phobias, fears and specific anxieties will not normally need any medical consultation before BWRT®. 8. There is no need for prolonged investigation into your early (childhood) years but if you feel they might have a bearing on your symptom, you can tell the practitioner and they will take that into account. 9. If your symptom was triggered by a past situation or trauma, you will be required to recall it for just a few seconds so that the degree of discomfort can be accessed via the Perceived Arousal Level (PAL). This also allows assessment of the degree of improvement after the process has been applied. 10. All therapies can occasionally create emotional arousal; this usually dissipates during the session but may sometimes last longer and does not indicate any problem with the therapy. 11. The practitioner may sometimes use their voice in a way that sounds unusual or strange to you. This need not concern you and is just part of the BWRT® Process. 12. There are several different ways that BWRT® can be conducted and the practitioner will be able to make the best choice for you and your presenting issue. 13. If the symptom or difficulty for which you are seeking help is part of, or likely to be part of, any legal proceedings, please take legal advice before embarking on treatment, since BWRT® changes your perception and responses to past events. 14. You may be asked if we can use the results of the work anonymously. This is completely optional with anonymity guaranteed (we use only the data), and if you do give consent, you can withdraw such consent at any time.

Confirmation of Understanding:*

Yes, I agree to the informed consent.

By signing below, you confirm that you have read and understood the above information and that you subsequently consent to BWRT® for your condition.

Digital Signature - By Typing in Name, you agree to all terms.*

Signature

Welcome to Your Journey of Transformation with Donna

BWRT New Client Paperwork Form 2024

WISE MIND BWRT - Disclosure and Disclaimer Form

Please List 7 (Positive/Happy) Benefits of Making The Change You Desire

Agreement for Success with Wise Mind Hypnosis/ Wise Mind BWRT

BrainWorking Recursive Technique® (BWRT®) - Informed Consent for Treatment

By signing below, you indicate that you understand and accept the following (presented in no particular order):