CLIENT DISCLOSURE
WHEREAS, Rachel Toback agrees to provide hypnosis services or life coaching services in accordance with acquired education and training to the undersigned (the “Client”) for good and valuable consideration from Client;
NOW THEREFORE, Rachel Toback represents the following to Client regarding the services offered:
Contact Information:
My name is Rachel Toback. I operate out of Portland, Oregon under LULLWATER LLC. I can be contacted through email.
My email address is info@lullwaterhypnosis.com
Education and Training:
I trained in hypnotism at the Northwest Hypnosis Institute and received my Hypnotist Certification from the National Guild of Hypnotists.
Affiliations:
I am a Certified Member of the National Guild of Hypnotists and I complete annual continuing education to maintain high level training. The National Guild of Hypnotists is the oldest and largest hypnotism organization in the world and its certification is the most widely recognized credential for the professional practice of the hypnotic arts.
Notice:
THE STATE OF OREGON 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 or a licensed health care provider. Under Oregon law, I may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. My credentials do not imply state or city licensing or education in any professional medical, health, therapeutic, emotional counseling, psychiatric, psychological or sociological field.
Client Rights:
If Client desires a diagnosis or any other type of treatment from a different practitioner, Client may seek such services at any time.
In the event my services are terminated by Client, Client has a right to coordinated transfer of services to another practitioner.
Client has a right to refuse hypnotism services at any time.
Client has a right to be free of physical, verbal or sexual abuse.
Client has a right to know the expected duration of sessions.
Client may assert any of the above rights without retaliation.
Redress:
I am a certified member of the National Guild of Hypnotists, and practice in accordance with its Code of Ethics and Standards. If you have a complaint about my hypnosis services or behavior that I cannot resolve with 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.
Fees:
The charge for my services is typically $100.00 per one hour session. Sessions are generally 60 to 90 minutes in duration. Clients will be given thirty (30) days notice of any change in fees. Payment options include cash, check and Venmo. Generally, insurance companies do not cover hypnosis services and as a result, I do not process insurance claims at this time. A limited number of sliding scale sessions are available per month. If you feel that a sliding scale option could apply for you, please email me at info@lullwaterhypnosis.com for more information.
No-Show/Late-Cancellation Fee:
All appointments must be cancelled twenty-four (24) hours prior to the scheduled appointment to avoid charges for a no-show or late-cancellation. There is a $50.00 no-show/late-cancellation fee if a client is late or misses an appointment. Clients must call and leave a message at 831.566.7455 to cancel an upcoming appointment.
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 records about you. I share a recorded copy of our sessions together with you so that you can continue to use them. When I deliver the digital copy it is then the client’s responsibility to keep it confidential. I will keep my copy of the recording confidential. Please note: we are supporters of Oregon’s reporting of child abuse laws and will report any such matters to the relevant state bodies.
My Approach:
Hypnotism means the use of trance and suggestion to adjust habits of thought, feeling and behavior. I use hypnotism with clients to motivate them to eliminate negative or unwanted habits, facilitate the learning process, improve memory and concentration, develop self-confidence, eliminate stage fright or social nervousness, improve athletic abilities, maximize skills and for other social, educational and cultural endeavors of a non-medical nature.
Services:
The services I render are held out to the public as non-therapeutic hypnotism, defined as the use of hypnosis to inculcate positive thinking and the capacity for self-hypnosis. I do not represent my services as any form of health care or psychotherapy, and despite research to the contrary, by law I may make no health benefit claims for my services. If for any reason during a client session, at my sole discretion I may terminate or refer Client to a different hypnotist if I think Client is not a good fit.
The successes using my services and forms of treatment are dependent on many variables, including attitude, motivation, cooperation, practice and the attendance of scheduled sessions. To reach the best results, Client must follow instructions provided.
Acknowledgement:
I, the undersigned Client acknowledge that I have received a copy of this Client Disclosure and by signing attest that I have read and understand the information provided, and that I consent to e-sign this agreement with LULLWATER LLC.