Dear Future Client,
Welcome to Hypnosis for Performance. I am committed to bringing you the best practices and services available in hypnotherapy, meditation, and learning and performance enhancement training. As you embark on this new journey (or well-traveled path), I am excited about the new discoveries you will make about yourself and your abilities as you learn techniques to create a performance enhanced lifestyle.
To assist me in making your first session an exceptional experience, please be prepared with the following:
1. NEW CLIENT PAPERWORK: Please read and fill out this entire form. It is very important.
2. CHILDREN: If your child is under the age of 18, s(he) must be accompanied by an adult.
3. PAYMENT POLICY: Full payment is due by the time of service. We do not bill insurance. We accept cash, check, or credit card. Most clients find it easiest to pay via PayPal.
4. CANCELLATION POLICY: 24-hour notice is required for all cancellations. There is a charge for all missed appointments.
Please arrive a few minutes early for in-person sessions, or be ready to Skype at least 10 minutes prior to our scheduled appointment.
Thank you for preparing for your visit. I am excited to work with you!
Anna Zumwalt, CHT
STATEMENT OF DISCLOSURE
Anna Zumwalt is a registered and certified Clinical Hypnotherapist, registered with the A.C.H.E. since 2013. She is a noted meditation instructor, a motivational/inspirational public speaker, and hypnotherapist. She does various seminars and workshop training on a variety of subjects and courses for business professionals, athletes, students and anyone with the powerful desire to excel.
Anna is an ordained Zen Priest in the Soto tradition, since 2003. She has had rigorous training. Though she can function in religious services, her hypnotherapy sessions are not necessarily religious in nature. Her clients can use their own religious beliefs or personal philosophies to understand their experiences, if they so choose. Anna’s Zen background makes her unique from other hypnotherapists. Hypnosis is the work of accessing the subconscious mind while Zen is the practice of accessing the conscious mind. In her ability to use both methods in her work, Anna’s clients have a unique opportunity for self-understanding and empowerment.
Anna’s personal mission is to help her clients believe in themselves and their abilities so that they can affect a positive future for themselves and others. She strives towards her mission by sharing the techniques she has learned with others in a caring and respectful way.
You must understand that the primary business of Hypnosis for Performance and Anna Zumwalt is to make available to clients instruction in behavior modification through the use of hypnosis, hypnotherapy, and self-hypnosis techniques.
Please understand and acknowledge that any suggestion or recommendation made to you has not been prescribed to you for the treatment of any known or unknown medical disease or illness by anyone. Understand that recommendations made to you by Anna Zumwalt are simply that, recommendations. Any purchase you make is of your own free will.
Payment is due before the time of the scheduled appointment.
If you are not happy with the results of our session when a week has passed, you may be given a full refund for the first hour. I make my business by helping people. If you do not feel that you were helped, please let me know.
Conversely, if you feel you HAVE been helped please share a positive review so that others will be inspired to be helped.
If you are happy with the work we do together, PLEASE let others know. I am beefing up my incentive program. Please ask me about it.
Your health information is private and protected by law. Your information will only be used or disclosed for the purpose of giving care, billing, or supporting day-to-day operations. You have the right to review your file. You may restrict all or part of your health information from being released. If you request information to be transmitted electronically, please be advised that your private information may not be protected. Anna Zumwalt transmits from a secure, encrypted network server. However, she cannot guarantee that any information you receive from Anna Zumwalt will be received through a secure network on your end. We will take every step necessary on our end to protect your privacy.
Confidentiality will be strictly maintained except for the following circumstances: (1) with your permission and a signed release of information to a particular person or agency. (2) By law, any report of physical, sexual abuse, or neglect of a minor, or abuse of a spouse or an elderly person. (3) If I have reason to assume that you may harm yourself or another person. I use a cell phone so that I am accessible, which cannot be considered 100% secure.
CANCELLATION OF APPOINTMENT
On occasion, a situation may arise which prevents you from keeping your scheduled appointment. Please notify me (Anna Zumwalt) 24 hours in advance of your appointment if you cannot keep it. Except in emergency situations, you will be expected to pay for any sessions that you miss without this advanced notice. If you cannot provide 24 hours advance notice, you have purchased the time as it was reserved for you, and will be billed accordingly.
By entering (typing) your full name and the date in the space indicated below you are consenting to these policies and authorizing my work with you and/or your children. You are also indicating that you have executed this agreement freely and willingly.