Name of Class ______
KS HYPNOTHERAPY
7937 S. LANCASTER ST.
GILBERT, AZ 85298
Phone (480) 440-7438
GROUP INFORMATION AND PARTICIPATION AGREEMENT
Kathryn Smith provides Integrative Hypnotherapy and Psychotherapy, Self-hypnosis, Relaxation, tapping training and Seminars. Her office is at 7937 S Lancaster St, Gilbert 85298. She does Office and Home Visits, Workplace Visits, and Offsite Facilities. She is registered with the International Association of Counselors and Therapists No 031315-7697. To validate training, please contact IACT or email
Please answer honestly and know that answering yes or no to any particular question does not mean that you cannot receive services. All information will be kept confidential.
Name______
Address______
City______State______Zip Code______
Email Address______
Phone Number ______
Can a message be left at this number? Y N
Can a text be sent to this number? Y N
Date of Birth ______Age ______
Marital Status ______
At the time of this class, do you suffer from a mental illness (if yes, please specify)?
Y N
Are you currently under a physician care for the above conditions? Y N
Have you spoken to your physician about attending this class? Y N
Like the practice of counseling, hypnotherapy, self hypnosis and group work are not absolute sciences. I personally know of no case on record where an individual has been harmed by the use of these methods. I do know that thousands of people have been greatly helped from the use of these methods. For hypnotherapy to have good success the client must want the change and be open to hypnosis. As a general practice, it is necessary for everyone taking part in private sessions, classes, workshops, groups, seminars or training with Kathryn Smith to sign this disclaimer.
By signing this, you have agreed as part of a group class to respect the confidentiality of other group members and not discuss other participant’s issues that were brought up in this class. Participants who are working through personal issues in this class may need to seek a medical professional to work through these issues. Personal issues may be brought up in this class. This is not a therapy class and personal issues may need the care of either a medical professional or individual sessions with a Hypnotherapist.
I am of legal age / I am the legal guardian of the minor (delete what is not appropriate) and in consideration of my acceptance as a participant in this Hypnotherapy session, whether it is Private, Class, Workshop, Group, Seminar or Training, I, for myself, my heirs, my executors, administrators and assignees, do hereby release and discharge Kathryn Smith and any of her employees, or other participants in any of the activities, from all claims of damages arising from, or growing out of my participation. I further understand that recordings may be made at any of these events, and that Kathryn Smith and her organization retain the copyright to all of these recordings.
Any fees payable are payable in advance unless otherwise stated or agreed.
If you should have a complaint about the facilitation process that has not been satisfactorily resolved by Kathryn Smith or her organization, please feel free to contact the International Association of Counselors and Therapists. It is your right to seek services of another Hypnotherapist at any time.
Signature ______Date ______
If under eighteen years of age:
Legal Guardian ______Date ______
KS HYPNOTHERAPY
7937 S. LANCASTER ST.
GILBERT, AZ 85298
Phone: (480) 440-7438
CONFIDENTIAL INFORMATION
Clients have a right to expect that information revealed in session will not be disclosed without extraordinary justification. The conditions that justify the release of information and by law must be reported to the appropriate agencies are the following:
1. Knowledge of child abuse
2. Knowledge of senior citizen abuse
3. A client poses a serious risk of suicide and is an imminent danger to self
4. A client poses a threat of imminent danger to another person
5. A judge, by issue of a court order, seeks to obtain information
6. A report to law enforcement authorities if knowledge of a felony has been, or will be, committed
In all other situations, signed authorization must be obtained before information is released.
Client/Guardian______Date______
Hypnotherapist ______Date ______