Client Intake Form

In recognition that millions of Californians receive a substantial volume of healthcare services from complementary and alternative health care practitioners, California Law allows access by California residents to complementary and alternative healthcare practitioners who are not providing services that require medical training and credentials.

A hypnotherapist is not a licensed physician or psychologist and hypnotherapy services are not licensed by the State of California. Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures.

I understand that the program of conditioning offered by hypnosis will include an undetermined number of private sessions, depending on my individual needs. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement (Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state. Those problems of psychogenic or functional origin are treated by psychological or medical referrals only.

While hypnosis may be an effective technique for many purposes, the effectiveness may vary from individual to individual. I also understand that there are no guarantees as to the results or progress to be made, only that Gila M. Zak, Certified Hypnotherapist will, to the best of her ability, endeavor to accomplish the objective of my sessions.

Hypnosis works with the power of the subconscious mind to change habits and behaviors. The subconscious mind is considered to be the source or root of many of our behaviors, emotions, attitudes and motivations. Hypnosis is believed to be a powerful tool for accessing the subconscious mind and creating improvements in our lives.

During hypnotherapy sessions clients remain completely aware of everything that is going on. In fact, many people experience a hyper-awareness where sensations are perceived enriched and vivid. The ability to visualize or imagine is often enhanced. Deep relaxation is common. Many describe the hypnotic state as a complete and total escape from physical tension and emotional stress, while remaining completely alert.

The use of hypnosis could elicit memories of past events which may or may not be literally true. It is possible that events under hypnosis will be distorted or misconstrued. Memories or images evoked under hypnosis are not necessarily accurate and may be a construction or a composite of memories. Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client.

While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in therapy.

Appointments cancelled with less than 24 hours’ notice may be subject to a late cancellation fee of $75. Appointments booked with failure to show will be charged the full session fee.

I have received a copy of this disclosure and understand the information described above.