Client Information

Purpose of Visit

Medical History

If you wear hard contacts please remove them before your session.

Contact Information:

Your hypnotist can be contacted at the main office: Mind Matters Hypnosis Center, 705 Boston Post Rd. Suite 5B Guilford, CT 06437, by telephone at 860-693-6448 or via e-mail at info@mindmattershypnosis.com

Education & Training:

The hypnotists working at Mind Matters are Certified or Board Certified in hypnosis by the National Guild of Hypnotists and/or The California Institute of Healing Arts and Sciences. Associations include the NGH, The American Hypnosis Association and The Hypnotherapists Union. Training has been extensive and includes but is not limited to certifications in Complementary Medical, Clinical, Regression, Child & Adolescent and Forensic Hypnosis. In addition, we commit to an additional 100 hours of generalized training and a minimum of 25 hours of specialty training per year.

Notice:

“The STATE OF CONNECTICUT HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY. Under Connecticut state law a hypnotist may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event our services are terminated by a client, the client has a right to coordinate transfer of services to another practitioner. A client has a right to refuse hypnosis services at any time. A client has a right to be free of physical, verbal or sexual abuse. A client has a right to know the expected duration of treatment and may assert any right without retaliation.”

Redress:

We are Board Certified/Certified members of the National Guild of Hypnotists and practice in accordance with its Code of Ethics and Standards. If you have a complaint about our services or behavior that we cannot resolve for you personally, you may contact the National Guild of Hypnotists at P.O. Box 308, Merrimack, NH 03054, (603) 429-9438, or The American Hypnosis Association at 18607 Ventura Boulevard, Suite 310 Tarzana, CA 91356, 800-479-9464 to seek redress.

Fees:

The charge for our services ranges from $250-$350 per session, depending on session length and level of practitioner experience. The majority of issues can be addressed in two to five sessions. Due to session length, we can only see 4 clients per day. The client will be charged the full non-refundable fee on the day of the booking if they have canceled one session in the past. Forty-Eight (48) hours’ notice to cancel or change an appointment is required. Failure to provide notice will result in a charge of 100% of the session fee.

Confidentiality:

We will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to our written records about you.

Safety:

Nothing considered to be a weapon is permitted inside the office building.

Our Approach:

We sincerely believe that we all harness incredible untapped power within our minds. Our practice of hypnosis is designed to tap into that power and assist people in using that power to better their lives. We are not “medical” or “psychological” professionals and as a result do not work with physical or mental disease without a referral from a licensed medical or psychological professional.

Hypnotic Intentions:

Your subconscious mind, the part of the mind you’re going to access during hypnosis, is the goal or action oriented part of your mind. As a result, it’s best to get clear about your goals or intentions prior to starting your hypnotic process.

Please put your measurable goal(s), in priority order, below. E.g. As a result of our work together I intend to permanently release 20 pounds of excess weight within 10 weeks.

As a result of my hypnosis session(s) I intend to:

Once you have your goals outlined it’s recommended that you spend a few minutes per day, prior to your sessions, visualizing yourself having achieved your goals and experiencing all the benefits of your success.

Release

Two – Way Release of Confidential Information

to release to each other any and/or all medical, psychological or educational information they may have pertaining to me.

This authorization for the release of confidential information expires ninety (90) days from the date above. I understand that I may revoke this release at any time on written notice to the parties involved, and the information released prior to the receipt of such notice is not a breach of my right to confidentiality.

One – Way Release of Confidential Information

the following specific medical, psychological or educational information he or she may have pertaining to me

I state that I have examined the records to be released and approve of this release to the party indicated above. This authorization for the release of confidential information expires ninety (90) days from the date above. I understand that I may revoke this release at any time on written notice to the parties involved, and that information released prior to the receipt of such notice is not a breach of my right to confidentiality.

Smoking Cessation Homework

Congratulations on your decision to become a non-smoker. Please complete the following homework as soon as possible so that you’ll begin your process of quitting even before you come in for you session.

1. Consider switching to a “natural brand” of cigarettes to ease any withdrawal sympotoms and begin to disconnect from your brand.
2. On a piece of paper that will fit into the sleeve of your pack make a list of all the things that you HATE about smoking. E.g. yellow teeth, bad breath, smell, cost, cough, low energy etc. Put it in the sleeve of your pack and read it before you light up.
3. Make another list of all the benefits that you’ll receive as a non-smoker and put that list on the other side of your pack and read it when you’re done smoking.
4. When you’re smoking – just smoke. It’s only a few minutes of your time and it is important for you to become conscious of exactly how cigarettes smell, taste and feel. So no driving, no talking on the phone, no working on the computer – just smoking. And, don’t hold your cigarette – put the cigarette down between puffs.
5. Get a calculator and figure out how much money you’ve spent on cigarettes and cigarette related illness since you started smoking. Then figure out how much time you’ve spent since you stared smoking. Then make a list of 3 things you would have rather spent that money and time on.
6. Have your last cigarette a half hour prior to your session and announce to yourself and to that cigarette that it is your last. E.g. “This is my last cigarette. I am now a nonsmoker and will be a nonsmoker for the rest of my life. Cigarettes you are no longer in control of me. I’m in control of me – my thoughts, my actions, my health and my money. I am a NON SMOKER!!!!”
7. Bring your homework and any remaining cigarettes or lighters with you when you come. You will be a non-smoker when you leave the Center. Congratulations!!

Weight/Food Input Form

Weight Release Growth Work:

Step 1: Simply become aware of what you’re eating. The best way to become aware is to accurately write down whatever it is that you’re eating throughout the day so we’ll be starting your process with accurate information. Or better yet, load the Cronometer App into your phone and log what you’re planning on eating for each meal prior to eating.

Step 2: Become aware of why you’re eating. Physiological hunger, boredom, stress, other emotions and make a note of the reason next to the food so we can become aware of any patterns of emotional eating.

Step 3: Please weigh yourself before your first session, again so we’re working with accurate information. If you’d like to take measurements of your waist, hips, upper arms and thighs you’re welcome to.

Step 4: If you’re not doing any exercise currently make a commitment to do something – anything that equals moving your body for 10 minutes per day before your session. E.g. walking, dancing, yard work, biking, stretching, playing with your children, etc.

Step 5: Get a refillable water bottle that you like – ideally one that’s at least 32oz – glass or metal. And if you feel that walking is going to be your primary form of exercise it’s worth investing in a simple pedometer.

Step 6: Bring your homework with you when you come. See, you’ve already taken six steps down your path to lean, fit and healthy. We look forward to working with you.

Dear Health Care Provider

requesting instruction in self-hypnosis.

It is our policy to be sure that the attending physician or other health care providers are aware that their patient is practicing hypnotism and will, as research supports, experience several positive shifts in their overall health as a result.

Consulting Hypnotism is motivational coaching by means of hypnotism and is not considered health care. Therefore, health insurance does not normally cover hypnotism and your patient will be paying us directly for our services.

If you have any objection to your patient receiving hypnotism please inform us immediately at (860) 693-6448 or info@mindmattershypnosis.com. If there is anything in specific you would like us to include in our work with your patient, such as pain control, appetite management, blood pressure or diabetes management, stress reduction, smoking cessation, anger management etc. please let us know.

We are Consulting Hypnotists in good standing with the National Guild of Hypnotists and our continuing education is current. We practice in accordance with the Code of Ethics, Standards of Practice and Recommended Terminology of the National Guild of Hypnotists, and give every client a comprehensive Client Bill of Rights which fully discloses our training and practice limits.

Please feel free to learn more about our services and longstanding service to the community, on our website at www.mindmattershypnosis.com. We would also be happy to discuss our services with you and/or your staff at your convenience.

In health,

The Mind Matters Hypnosis Team

Avon, Glastonbury & Guilford, CT

MindMattersHypnosis.com

(860) 693-6448

Parent Approval Form

and my child are confidential and will not be shared with me without the expressed permission of my child.