For Review – To be completed in the office:
By signing this information sheet, I, the undersigned client (or guardian for a child client under the age of 18) acknowledges that I have been informed of the following:
I, Tammie S. Roitman, a Nationally Certified Clinical Hypnotherapist, agrees to provide professional services in accordance with professional best practices and principles of hypnotherapy and will provide undivided attention during scheduled sessions for the benefit of the client.
The principles of certified clinical hypnotherapist are exclusively client-centered. Methods use hypnosis to facilitate the discovery of inner creative abilities. In this manner, certified clinical hypnotists promote their clients positive thinking and emotions that help transform undesirable habits to functional and productive behavioral replacements. Therapeutic success allows for better, more efficient problem solving methods to solve personal problems, improved motivation and productivity. When clients reach their therapeutic goals they experience more freedom from restrictive thoughts and inhibiting belief systems. By learning self-hypnotic techniques they can use their acquired skills in their daily lives.
To establish therapeutic goals, clients (or guardians) can explore their options and personal history with the hypnotherapists and reach agreements on objectives and methods.
Hypnosis is not a kind of sleep. It is a natural state of mind that facilitates extraordinary, progressive relaxation of the mind, body and emotions. The principles hypnotherapy is based on accesses the power of the client’s own inner resources.
Hypnosis transcends the inhibiting, critical, analytical level of the mind, and promotes the open minded acceptance of suggestions, directions and instructions the client (or guardian) prefers. The therapeutic use of hypnosis can elicit forgotten information and improve inner connections and insight from the subconscious mind. The hypnotherapist uses interviews and hypnotic methods to help the client deal with the subconscious issues when appropriate, with the goal of establishing effective and lasting results.
Hypnotherapy is not the practice of medicine. Hypnotherapist are not licensed physicians. Hypnotherapy does not depend on diagnosis and hypnotherapists do not form diagnoses. Hypnotherapy is frequently complementary to other healing arts.
In the state of Nevada, certified clinical hypnotherapists are awarded a general license that requires the hypnotherapist to be a member in good standing of the International Board of Hypnotherapy, National Guild of Hypnotist, or The American Council of Hypnotist Examiners.
The primary purpose of licensing laws for legally defined “Healing Arts and Mental Health Professionals” is to protect public health and safety of Nevada citizens. Accordingly, hypnotherapists are not issued a license by state governmental agencies to engage in their professional services.
This statement is to certify that I Tammie S. Roitman, have acquired a national certification as a Certified Clinical Hypnotherapist from The American Council of Hypnotist Examiners. This certification demonstrates that I acquired the necessary education, training, experience and qualifications to perform Certified Clinical Hypnotherapy to my clients.
Certification and state law requires me to state clearly that I am not a clinical psychologist, MFT, mental health counselor, drug and alcohol counselor or LCSW. I am not representing represent myself as a licensed clinical psychologist, MFT, mental health counselor, drug and alcohol counselor or LCSW. I am a trained clinical hypnotherapist and State of Nevada licensed School Psychologist under the Department of Education in the State of Nevada.
I, the undersigned client (or guardian for a persons’ under the age of 18), acknowledges that Tammie S. Roitman described the principles of Certified Hypnotherapy and disclosed the lack of state licensure of psychological, social work, marriage and family, mental health counselor or drug and alcohol therapy credentials, provided the opportunity to ask questions and provide answers, to my satisfaction. I was provided a copy of this “Client Information” form and understand the foregoing information.
|Client’s name (print)