Lasting Light Wellness Consent and Release Form

5305 Village Center Dr. Suite 205
Columbia, MD 21044
 (410) 446-2544

Hypnosis
I or the minor child listed on this form consent to participate in the process of hypnosis, with Lasting Light Wellness LLC. I understand that hypnosis can involve the use of techniques such as progressive relaxation, meditation, guided imagery, as well as other helpful methods.

 

I understand that clients vary greatly in their response to the hypnotic process, with some clients having powerful experiences and others experiencing relatively little. We cannot and will not predict outcomes or make decisions for you. I understand that no warrantees have been extended and no specific outcomes have been guaranteed. I assume full responsibility for my actions and inactions which relate to any sessions.

 

Additionally, I am aware that the experiences during hypnosis may be a combination of real and/or imagined. I also understand that certain memories/experiences may invoke emotional reactions, they may be emotionally challenging for some clients. I understand that if at any time I become uncomfortable and/or unwilling to proceed with the hypnosis process, that I can request to stop the process and the hypnotic portion of the session will terminate.

 

I understand that Hypnosis is not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Hypnotist does not treat, prescribe, or diagnose any condition.

 

I grant permission for the sessions to be recorded if needed. I understand that if there is any recording made of a session that it is for your personal use only and that it is not to be lent, copied, or sold under any circumstances. Do not listen to hypnotic material while driving, operating equipment or any other potentially hazardous situation.

 

If you have a legal case pending one in which you plan to testify. You should give statements or written testimony before doing any type of hypnosis that is related to that situation. It is not advised to do memory retrieval hypnosis for a situation that you plan to litigate.

 

Please read and follow the hypnosis guidelines that have been sent to you so that you may have an optimal experience.

 

In Person Hypnosis
I understand and give permission that during the session, my practitioner may gently touch me on the forehead, neck, shoulder, arm, hand, or wrist as part of a hypnotic technique.

 

Online Hypnosis
We are not responsible for inferior conditions on the client’s end such as noise, distractions, poor internet/phone connections, clients falling asleep etc. We are not required to refund or redo sessions for things that are out of our control on the client’s end. If a recording was requested and there were technical issues it is at our discretion to re-record, grant you access to similar material, or find another solution.

 

Late/Canceled Appointments
Out of respect and consideration your practitioner and other customers, please plan accordingly and be on time. If you are going to be late or are having problems the day of your appointment, please contact us at 410-446-2544, we will do our best to accommodate you. If you are late, we cannot guarantee a full appointment time, you may forfeit the portion of your appointment that you were late. 1st no show or cancelation in under 24 hours is charged a $35 fee per hour all subsequent no shows are charged the full session price, or one package session will be redeemed.

 

Packages
All package/multiple session purchases are good for one year from the date of purchase. They may be redeemed at purchase price for items in our store or gifted to another with written notification. After a year all value will be forfeited.

Name (printed) participant or legal guardian for minors:

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