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Consulting and Hypnotherapy
Client Consent & Background Information
© Lauren Archer – 425-881-7082 – www.PositiveCentral.com
New Clients: Please read the following.
You may print and sign the forms embedded in this document,
or sign a copy in my office.
Click here for the Legal Notice from the Washington State Department of Health.
Introduction by Lauren Archer
Thank you for scheduling your Hypnotherapy and/or Consulting appointment. I'd like to congratulate you on your decision to access the power of your inner mind and heart, and thank you for trusting me to be your guide.
This page contains important information for your review, including background information, legal information about your rights from the State of Washington, a consent form for you to sign, a questionnaire for you to complete.
Lauren's Home-Office
Nestled in the beautiful woods of Woodinville, my secluded, round office provides an ideal setting for your private session. To protect our privacy, the address is not posted on this website. I will send you the address and detailed directions once we confirm your appointment. We are located in the English Hill area, near Avondale Road and NE 128th Street, on the border of Redmond and Woodinville. Call 425-881-7082 to schedule.
What can you expect from your session?
- You are always in charge of your appointment plan.
- Your session will begin with a relaxed interview where I will listen to your specific goals and issues.
- We may "brainstorm" together about creating a realistic, strategic plan to incorporate the changes you are seeking to make in your life.
- You will be informed about what to expect during the hypnotic induction and have the opportunity to address any concerns.
- I may offer tips and suggestions for learning specific skills, such as self-hypnosis or stress relief techniques.
- Your hypnotic induction may include relaxation, guided imagery, and positive suggestions for change.
- It doesn't matter whether or not you "go under" during your session in the office because your hypnotic induction will be recorded for you.
- You will receive a CD of your hypnotic induction to listen to as many times as you like in the comfort of your own home.
- As you listen to the recording over time, it will reinforce the positive suggestions for maximum impact, and help you build powerful new skills that you can apply in other areas of your life.
- There are no long-term contracts or hidden fees.
- You can select one session only, or schedule weekly or monthly sessions. It's up to you.
I look forward to getting to know you.
With appreciation,
Lauren Archer
Clinical Hypnotherapist
Licensed HeartMath(R) Provider
President, Positive Central
Past President, National Guild of Hypnotists, Washington State Chapter
Executive Director, Eastside Women in Business
ACE Certified Personal Trainer
Office Telephone: 425-881-7082
Email Address: Lauren@PositiveCentral.com
Mailing Address: P.O Box 2578, Redmond, WA 98073
BACKGROUND INFORMATION
Hypnosis is a naturally occurring state, which is beneficial and restorative. While I am confident that only benefit will accrue from using hypnotic techniques, I am required to state that you do so at your own risk.
Please read the following documentation, and sign below.
The information contained within this document is provided to instruct the client about the nature of Hypnosis, Hypnotherapy, Guided Imagery, and Self-Hypnotic Techniques, and to inform the client about the wholesomeness and usefulness of these techniques in facilitating healthy lifestyle changes and/or alterations in personal habits for self-improvement.
Hypnosis is completely safe. You are in control at every moment and can terminate the hypnotic state at any time. Hypnosis is not sleep. You cannot get “stuck” in hypnosis. You cannot be made to do something against your will. Hypnosis and self-hypnosis is used by Olympic athletes, corporate executives, musicians and artists, and peak performers in all walks of life.
Hypnosis, Hypnotherapy, Guided Imagery and Self-Hypnotic Techniques are not meant as a substitute for standard medical, psychological or psychiatric treatment for serious or life-threatening conditions, such as medical trauma, surgical emergencies, bacterial infections, certain bodily "mechanical" difficulties, and thought disorders such as psychosis or schizophrenia. These techniques are an adjunctive/complementary alternative for self-healing, self-help, and behavioral modification. Potential clients under the age of 18 must provide written consent by a parent or legal guardian to use any services provided by Lauren Archer.
Lauren Archer makes no expressed or implied guarantees of results, in so far as human behavior cannot be predicted. The client is duly informed that as individuals vary, so do results, and that all hypnosis is self-hypnosis. Results are ultimately achieved through the client's own personal efforts at applying these techniques over time, for which each client must accept full responsibility.
Education and Training: I hold a Bachelor of Science degree in Mass Communication with a minor in Psychology from Illinois State University, 1984. I completed my training in hypnosis at the Palo Alto School of Hypnotherapy in 1992 and 1993. My certifications include Hypnotherapy, Advanced Hypnotherapy, Inner Child Therapy, Clinical Hypnotherapy, and Regression Therapy. I am a Certified Member of the National Guild of Hypnotists. I served two terms as President of the National Guild of Hypnotists, Washington State Chapter. I was certified with ACE (American Council on Exercise) as a Certified Personal Trainer in 2003. I am a Licensed Provider for HeartMath(R). I attend annual continuing education courses to maintain my training at a high level.
Notice: “THE STATE OF WASHINGTON HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY. Under Washington State law a Hypnotherapist may not provide a medical diagnosis or recommend discontinuance of any medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to coordinated transfer of services to another practitioner. A client has a right to refuse hypnosis services at any time. A client has a right to be free of physical, verbal or sexual abuse. A client has a right to know the expected duration of treatment, and may assert any right without retaliation.”
Redress: As a certified member of the National Guild of Hypnotists, I practice in accordance with its Code of Ethics and Standards. If you ever have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the National Guild of Hypnotists at P.O. Box 308, Merrimack, NH 03054-0308, (603) 429-9438, to seek redress. Other services than my own may be available to you in the community. You may locate such providers on the Resources Page on my website, or through the Nat'l Guild of Hypnotists, Washington State Chapter (www.nghwa.org), or through the Washington State Holistic Chamber of Commerce, or in the telephone book or by searching the internet.
Fees: The charges for my services are $150 per hour. First time sessions require 90 minutes. Fees are subject to change. Payment is expected at the conclusion of each session, unless previous written arrangements have been made. Payment may be made by check or cash, or securely online via Paypal. If paying online, please do so in advance of the session. There will be a $20 fee for insufficient funds on checks.
Insurance: I do not bill insurance companies directly, however, I can provide documentation for you to provide to your insurance company.
My Approach: We all have within us the power to express our own uniqueness and achieve our full potential. It is by understanding the levels of consciousness that we can begin to recognize and overcome many of the obstacles to our success. My passion is to teach the basic principles of how the mind works, to empower others to reach their potential and to achieve their goals through developing positive habits.
Download and print your forms in a Microsoft Word document to bring to your session.
INFORMED CONSENT
Please complete the Informed Consent and Questionnaire portions and bring them to your session.
I have read and fully understand the information in this document and in the Legal Notice from the Washington State Department of Health.
I agree that I am responsible for my own choices. I will make my own decisions regarding my lifestyle behaviors. I realize that if I have any medically or psychologically diagnosed conditions, I am being advised to seek my doctor's approval. I understand that Lauren Archer is not a medical or psychiatric professional. I will hold Lauren Archer harmless and release her from any liability from loss or injury before, during or after hypnotherapy, guided imagery, or general consulting.
Client name: __________________________________ Date: __________________________
If client is a minor, parent or guardian name: _________________________________________________________________
Relationship to client:__________________________________________________________________________
Legal Signature:_______________________________________________________________________
Address:_______________________________________________________________________________
Phone(s):________________________________________________________________________
Email Address: ______________________________________________________________________
Date of Birth (mo/day/yr): ______________________________
Emergency Contact Information:____________________________________________________________
Who may I thank for referring you? ________________________________________________
NEW CLIENT QUESTIONNAIRE
1. Please describe the primary issue you would like to address:
2. What is your current situation related to the above condition?
3. What methods have you already used related to this condition?
4. What has worked, to what degree?
5. What has not worked, and what do you perceive your obstacles to be?
6. What is your most desired outcome related to this condition?
7. Are there specific times of day or sets of circumstances that you notice to be related to the condition?
Please describe.
8. Please describe, in as much detail as possible, what images are in your mind when you imagine your most desirable outcome. (Use the first person, i.e…“I am standing on a stage and speaking to a large audience of people who are very supportive and interested in my talk. I see myself walking the stage, feeling comfortable and confident, etc.)
9. Please describe what positive emotions you may feel when you imagine your most desirable outcome. (Example: “I feel comfortable, self-assured. I am proud to be serving others. I am radiating confidence. I am passionate about what I am speaking about, etc.)
10. Please describe how achieving your goal will make a positive difference in your life.
11. How will you measure your success? (Example, Successfully delivering a public speech, or being a non-smoker for 3 months, or losing 10 pounds, etc.)
12. How would you consider your previous experience with hypnosis/guided imagery/meditation? (Novice? Beginner? Intermediate? Advanced?) Do you have any questions or concerns regarding the process?
13. Please list any specific religious affiliation(s) or preferences:
14. Please note any additional conditions you may wish to address at this or future sessions:
____ Smoking ____Weight Management _____Peak Performance ____ Self-Esteem
____ Occupation ____ Relationships _____ Spirituality ____ Self-Control
____Motivation ____Improved Health _____ Situational Stress ____Other
15. If you are under a doctor’s care for any medical or psychiatric condition that relates, however remotely, to the current condition, you are notified that you must receive approval from your doctor to receive hypnotherapy, and that hypnotherapy may complement your healing process, but is not a substitute for medical treatment.
_______ Initial here that you acknowledge and understand the above.
© Lauren Archer – 425-881-7082 – www.PositiveCentral.com
Download and print your forms in a Microsoft Word document to bring to your session.
