Depth Hypnosis Waiver
Hello! Please read the following statements, and fill out our intake.  
Please let us know if you have any questions. Admin@holisticRI.com (401) 300-5010

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Email *
Full Legal Name *
Preferred Name
Preferred Pronoun
Date of birth (if under 18, parental release form is required) https://forms.gle/tHYwAyWYMjySjjTF8 *
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Phone Number *
Depth Hypnosis Release Statement
Hypnotherapy is a self- regulated, not state-licensed, profession. We are a certified profession,
and meet the highest standards set forth by the Association of Depth Hypnosis Practitioners and
the Foundation of the Sacred Stream. We practice according to our organization's Code of Ethics
and Standards. We have received high quality training through Depth Hypnosis Training Program
and the Foundation of the Sacred Stream. We do not do medical diagnosis; nor are we licensed
physicians or medical practitioners. We are certified healing arts practitioners - Certified
Hypnotherapists. We provide hypnotherapy services, which give high-quality alternatives for
people seeking to overcome many of the challenges of life. We pledge confidentiality.
Recent research has found that memories uncovered during hypnosis, or other forms of induced
altered states may not be accurate or even factual. Memory is a constructive and reconstructive
process. What is remembered about an event is shaped by what was observed, by conditions
prevailing during attempts to remember, and by events occurring between observation and
attempted remembering. Memories can be altered, deleted, and created by events that occur
during and after the time of encoding, during the period of storage, and during attempts at
retrieval.

Therefore, if memories should surface that may be considered grounds for future litigation during
the course of hypnotherapy, you may lose your legal right to use this information in a court of law,
as it may not be admissible. If certain types of memories begin to surface during any hypnosis
session, the session will be discussed so that you may decide whether or not to proceed further
with the hypnosis based on your understanding and careful consideration of the above
information.

Depth Hypnosis can bring up strong emotions and by signing this document you are indicating
that you feel stable enough to handle those emotions. The Hypnotherapist is not liable for any
pain or emotional distress that may ensue in the course of this work, and it is understood that you
will seek medical or psychiatric help as the need arises.


I agree to the Depth Hypnosis Release Statement above. I understand it fully and give consent to a Depth Hypnosis session.   *
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Holistic RI Practitioner Permission - I give permission for Holistic RI practitioners and providers to review this intake and share clinical  findings. Only practitioners providing direct therapies or consulting will access this information. We take your privacy very seriously. *
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