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: $525 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.
Consent * I agree to the rescheduling policy and agree to pay for missed appointments.
Life happens! If for some unforeseen reason you cannot keep a scheduled appointment, you will be sure to provide 48-hour notice (2 business days) if you need to reschedule, at which time, the appointment will be rescheduled for a later time. If advanced notice is not given, that 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.
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)
Consent * I agree to the following.
Your signature below indicates that you have read and understood the details of this disclosure document.