Diana Davis Hypnotherapy ~ Liability Waiver for Participant Safety and Well-being

Health Conditions Requiring Caution:

• Cardiovascular issues

• Elevated blood pressure

• Aneurysms

• History of epilepsy or seizures

• Heavy medication use

• Severe psychiatric symptoms, including psychosis, paranoia, or bipolar disorder

• Osteoporosis

• Recent surgeries

• Glaucoma

• Pregnancy

• History of anaphylaxis

• Asthma (participants should bring inhalers and consult their physician and the session instructor beforehand)

• Emotional or spiritual crises, or untreated mental health disorders without adequate support
  

This list is not exhaustive; if you have any health concerns not mentioned here, please consult a physician before participating. If any of the conditions above apply to you, contact me at 727.386.8613 before signing up to ensure you are cleared for participation.

Participant Health Declaration: 

I affirm that I am in good physical, mental, psychological, and emotional health to participate in breathwork sessions. If I am not in good health, I understand that I will not be allowed to participate.

The facilitator of breathwork is not a medical doctor, psychiatrist, or healthcare specialist, and the activities are not intended to diagnose or treat medical conditions.

Session Participation Agreement: 

I confirm that I will not attend the session under the influence of any substances. Failure to comply will result in being asked to leave, and the session will be rescheduled without a refund.

I voluntarily participate, understanding the risks involved, and I agree to assume all consequences, whether known or unknown.

I release the facilitator, Diana Davis, from all liability, costs, and damages that may arise from participation. I accept financial responsibility for any treatment costs incurred.

By adding my name below, I confirm that I have read and understood this waiver, and I agree to proceed with full responsibility. I acknowledge that by signing this form, I waive certain rights voluntarily and without any external pressure. Submitting my name and the date below serves as my esignature. 

 Name:    _______________________

Signature: _____________________

Disclosure Form

Contact Information: Diana Davis

Education and Training:  I was trained in hypnotism at the Institute of Interpersonal Hypnotherapy a Florida Department of Education state licensed school.  I am also a Master NLP practitioner and received my certification from National Federation of NeuroLinguistic Programming.

 Notice: AS THE STATE OF FLORIDA HAS NOT ADOPTED EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM, THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY.  Hypnotism is a self-regulating profession, and its practitioners are not licensed by state governments.  I am not a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of 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 to another practitioner.  A client has a right to refuse hypnotism 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 sessions, and may assert any right without retaliation.

Fees:  Vary depending on the session and packages.  Sessions typically last 1.5 – 2 hours.  Fees are due at the time of each session in the form of cash, check or credit card.  You will be given a 14-day notice of any change in fees.  I have a 24-hour cancellation policy; clients are charged for one and a half hours of time if they do not call to cancel or reschedule in accordance with this 24-hour notice.  Hours paid in advance in the form of package deals are good for 6 months from their time of purchase.  After 6 months of absence from hypnotherapy, these hours are forfeited.  Packages are non-refundable. 

Confidentiality:  I will not release any information to anyone without a written authorization from you except as provided for by law.  You have a right to be allowed access to my written record about you.  As my client you have the right to complete and current information concerning any aspect of the professional/client relationship.

Insurance: I suggest you think of my services as something that you will pay for personally.  That will both protect your privacy and help you value the work you are doing more.  In general, most insurance companies do not cover hypnotic services, and I caution you not to expect them to do so.

 My Approach:  It is my goal to help you to achieve lasting results through the use of hypnosis, NLP, meditation and other related self-help modalities.  Through the power of your own mind, I will assist you in reaching your goals in a way that you and I both agree to be in your best interest, and in a way that is in compliance with state and federal laws, as well as with the standards of the organizations to which I belong.  I agree to use my experience to facilitate the changes as are mutually agreed to be in your best interest.  I am professionally committed to helping you achieve your goals in a timely manner.

I am of legal age and understand I am entering into a cooperative relationship of my own free will. I accept that I am a willing participant in this cooperative relationship that will employ hypnotic techniques, regression, NLP and any other appropriate modality by Diana Davis.  Therefore, I being of legal age or with a parental signature if under 18 years of age, my heirs, executors, administrators and assignees, do hereby release and discharge Diana Davis, any of Diana’s employees from all claims of damages, copyright, demands or actions whatsoever in any manner arising from or growing out of my cooperative participation.  I understand that recordings may be made during my sessions for my personal ongoing use and with my preapproval and knowledge and Diana Davis retains the copyright of these recordings. Any concerns or questions can be addressed with the International Association of Interpersonal Hypnotherapist as the governing and credentialing body. I have received and read this Client Agreement and Disclosure Form and understand what I have read:

 Client Name: _______________________________________________________________________ 

 Client Signature: ___________________________________________________Date:_____________

 Parental Signature if under 18:_________________________________________________________

 Hypnotherapy is a self-regulated profession and does not qualify for state licensing in the United States. The International Association of Interpersonal Hypnotherapists is the credentialing body for The Institute of Interpersonal Hypnotherapy, a Florida Department of Education state licensed school offering career Diplomas in Hypnotherapy, Clinical Hypnotherapy and Transpersonal Hypnotherapy. The IAIH’s Ethics Committee can suspend or revoke certification of its members. Certification is awarded to those who complete 500 hours of training and receive State Licensed Diplomas from FIH. Alternatively, certification and membership is also granted to a hypnotherapist who has attended a state licensed school or the international equivalent, received at least 300 hours of training, and who has successfully completed the IAIH Interpersonal Hypnotherapy Course and passed the IAIH practical and written exam.  The IAIH has the highest standards and requirements for certification of any major hypnotherapy credentialing body currently in the United States. Hypnotherapists certified by IAIH have agreed to provide professional services in accordance with the IAIH Code of Ethics. IAIH Hypnotherapists practice within the scope of their individual credentials and engage in the profession legally and ethically.  IAIH Hypnotherapists also understand and embrace the hypnosis laws that regulate our profession on international, federal, state, county and city levels. The IAIH works with state and federal legislators to raise the industry standards and protect the practice of hypnosis by qualified practitioners.

 When you see the IAIH logo you have the assurance that the hypnotherapist is highly trained and certified. Clients choosing an IAIH Certified Hypnotherapist are entering into a professional relationship knowing it is a cooperative relationship designed to assist the client to reach their goals in a timely manner.  The IAIH defines hypnosis as a natural, yet altered, state of mind where communication and responsiveness with the subconscious mind is present.  Ultimately hypnosis transcends the critical and analytical level of mind and thought, providing a natural yet altered state wherein practitioners can help facilitate the acceptance of suggestions, directions and instructions desired by the client. Through IAIH hypnotic techniques and teachings the client’s deep inner mind can access information and insights necessary to extend themselves and others the forgiveness, understanding, compassion, acceptance and ultimately love necessary to produce a compassionate philosophy and state of being.

 IAIH Hypnotherapists are committed to honoring the importance of relationships in every aspect of the human experience.  In cooperation with clients and with mutually agreed upon goals, IAIH Hypnotherapists utilize their advanced training to personalize an approach to uncover life defeating and limiting belief systems of their clients, identify repeating negative patterns, and use sound principles and techniques to help clients discover their inner transformative power, reframe defeating or negative thoughts into positive truthful thoughts and feelings, and achieve effective and lasting results.

 It is the goal of every IAIH Hypnotherapist to  help clients achieve their goals as quickly as possible and to become obsolete in the client’s life in a timely manner by empowering each client with powerful techniques to  achieve goals and resolve issues through self-hypnosis, hypnotic reprogramming and reframing techniques. The IAIH Interpersonal hypnotherapist will utilize dialogues, and advanced hypnotic techniques honoring the sacredness of the relationship while working to uncover underlying patterns  or limiting belief systems and ultimately transforming those to align with the truth that all persons are perfect, whole and complete, and worthy of love, abundance and respect. Through this, the IAIH Interpersonal Hypnotherapist empowers the client, and together they achieve effective and long lasting results.