NEW CLIENT INTAKE FORM
ALL INFORMATION IS STRICTLY CONFIDENTIAL JENNI GLAD - CERTIFIED RAPID TRANSFORMATION THERAPIST/HYPNOTHERAPIST/LIFE COACH/REIKI MASTER
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
HEALTH
Date of last check up *
Date of last check up
FROM THE LIST BELOW MARK THE AREAS THAT CONCERN YOU
OTHER
I or my representative(s) agree to fully release and hold harmless Jenni Glad/Glad Unlimited LLC from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). Under no circumstances including but not limited to negligence shall Jenni Glad or any of her staff members be liable for any special or consequential damages in any way whatsoever now or in the future that results from the use of or the inability to use hypnosis / advanced hypnosis techniques / hypnotherapy or any other therapies used or coaching. The information, techniques, hypnosis, methods or recommendations by Jenni Glad is not intended to substitute for the diagnosis and care of a qualified physician nor to encourage the treatment of illness by persons not recognizably qualified. If you use hypnosis and are under the medical care for any condition do not make any adjustments to any prescribed medication without the approval of your doctor. If any doubt you should always seek your physician's advice. Epileptics should not enter hypnosis or anyone diagnosed as having the psychotic illness. I am approving these terms and conditions I understand and verify that all information is complete and accurate to the best of my knowledge. I also understand that the hypnotic methods used by Jenni Glad are not a substitute for medical or psychiatric treatment. I understand these methods to be a conditioning process, whereby an individual is taught to use their own abilities for their benefit and wellbeing. With this understanding, I hereby grant Jenni Glad permission to hypnotize me or the minor child whose name appears at the top of this form. I (we) further grant permission for the sessions to be recorded/taped as needed. I know my progress is dependent upon my efforts and that there are no guarantees as to the result or progress to be made. I understand that the success of the treatment will be in direct proportion to my commitment to the end result. The fees are billed upfront via Paypal, Stripe or cash and the payment or first installment of the payment plan needs to be received in order to begin our RTT relationship.If client has purchased a package and find oneself unable to use the sessions for any reason, client may put the remaining sessions on a 3-month hold. Session credits will not be carried out further than 3-months. The fees are nonrefundable. Jenni Glad only works with the clients who are committed. There will be no refunds as a matter of course. Glad Unlimited LLC retains the right, at its sole discretion, to refund payment in the event of extenuating circumstances where it may deem such action appropriate. Parties may terminate this contract at any time. The contract termination must be provided in writing to the other party with two days notice. It is the intent of the Parties that, notwithstanding any termination, the paragraphs concerning Confidentiality, Liability, Disputes and Miscellaneous will survive this Agreement. Client commitment 1. I have been advised by Jenni Glad the scope of hypnosis/hypnotherapy practice and I give my full consent to receiving hypnosis/hypnotherapy sessions by Jenni Glad now and in any future sessions. 2. I understand that results vary and that the practitioner may not guarantee results. 3. I understand that Hypnosis/Hypnotherapy/Coaching is not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Hypnotist/Hypnotherapist does not treat, prescribe for, or diagnose any condition. If Client believes that hypnotherapy is not working as desired, Client agrees to first communicate this to Jenni Glad. 4. I give the practitioner permission and consent to do so to help me establish a beneficial state of hypnosis. 5. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability. 6. I have accurately provided background information as requested. 7. I understand that confidentially regarding my sessions will be honored between Jenni Glad and me. This same confidentially is respected when working with minors under the age of eighteen. 8. I understand that, depending on the state of my mental health, further psychiatric treatment by may be needed and will be suggested to me and documented by Jenni Glad if she determines my situation to be outside the scope of coaching or hypnotherapy. By approving these terms and conditions, I am confirming that all information is true to the best of my knowledge and I completely understand and agree to the terms and conditions. All appointments not cancelled or rescheduled with 12 hours notice will be charged in full. By submitting this form and signing it with my initials, I am confirming that all information is true to the best of my knowledge, and I agree to all the terms listed above.