CONSENT FOR SERVICES 

This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider. 

THE HYPNOTHERAPY PROCESS 

Hypnotherapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. Hypnotherapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit. 

The program of conditioning offered will include an undetermined number of private sessions, depending on my individual needs. The major purpose of this program is for Vocational or Avocational Self-improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only. There are no guarantees as to the results or progress to be made, only that the Provider will, to the best of their ability, endeavor to accomplish the objective of my sessions. 

DISCLOSURE OF SERVICES 

The purpose of a program of hypnotherapy is for vocational and avocational self-improvement and as alternative or complementary treatment to healing arts services licensed by the state. A hypnotherapist is not a licensed physician or psychologist and hypnotherapy services are not licensed by the State of Minnesota. 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. 

Hypnotherapists who assist clients with weight loss and/or other health and fitness goals may provide general nutritional advice and/or recommend published books, food guides and health and fitness publications. This is not a substitute for medical advice and you are advised to seek your Doctor’s approval before making any medical/health/lifestyle changes. 

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. 

Services consist of a program of conditioning, including an undetermined number of private sessions, depending on the client’s individual needs. The hypnotist will to the best of his or her ability endeavor to accomplish the objectives of the client’s sessions. While hypnosis may be an effective technique for many purposes, the effectiveness may vary from individual to individual, and no specific results or progress can be promised or guaranteed.

The feelings and experiences one has in the hypnotic state can vary from individual to individual. Many people remain completely aware of everything that is going on while in hypnosis. Some individuals experience a hyper-awareness where sensations are perceived to be enriched and vivid. The ability to visualize or imagine is often enhanced. A feeling of deep relaxation is common and some people describe the hypnotic state as an 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. 

TELEHEALTH SERVICES 

To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth: 

• Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact and creating a communication plan.
• Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
• Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.  
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.

CONFIDENTIALITY

Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions. 

• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.

FEES AND PAYMENT FOR SERVICES 

You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy, and should confirm with your insurance if part or all of these fees may be covered. You should also know about the following: 

• No-Show and Late Cancellation Fees: If you are unable to attend therapy, you must contact your Provider 24 hours before your session. Otherwise, you may be subject to late/cancellation fees
• Administrative Fees: Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.
• Payment Methods: Payments will be handled through Stripe. 
• Session rates are as stated on website.

• If you purchase a package of sessions, all sessions in that package must be used within a one-year time frame with no more than 2 months in between consecutive appointments starting from the date of purchase. If your account has been inactive for more than 2 months or beyond a year from the initial start of the package, the rest of the sessions will be considered expired and nonrefundable.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

Hypnotic Solutions, (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain. 

YOUR RIGHTS 

Your rights regarding PHI are explained below. To exercise these rights, please submit a request.

To inspect and copy PHI. 

• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.

To amend PHI. 

• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.

To request confidential communications. 

• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.

To limit what is used or shared. 

• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.

To obtain a list of those with whom your PHI has been shared. 

• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.

To receive a copy of this Notice. 

• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.

To choose someone to act for you. 

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.

To file a complaint if you feel your rights are violated. 

• You can file a complaint by contacting the Practice 
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• The Practice will not retaliate against you for filing a complaint.

OUR USES AND DISCLOSURES 

1. Routine Uses and Disclosures of PHI

The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways: 

To treat you. 

• The Practice can use and share PHI with other professionals who are treating you. Example: Your primary care doctor asks about your mental health treatment.

To run the health care operations. 

• The Practice can use and share PHI to run the business, improve your care, and contact you. • Example: The Practice uses PHI to send you appointment reminders if you choose.

To bill for your services. 

• The Practice can use and share PHI to bill and get payment from health plans or other entities. • Example: The Practice gives PHI to your health insurance plan so it will pay for your services.

2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object

The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including: 

To help with public health and safety issues 

• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
• Serious threat to health or safety: To prevent a serious and imminent threat.  
• Abuse or Neglect: To report abuse, neglect, or domestic violence.

To comply with law, law enforcement, or other government requests 

• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
• Law enforcement: For law locate and identify you or disclose information about a victim of a crime. • Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance. • National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers' Compensation: To comply with workers' compensation laws or support claims.

To comply with other requests 

• Coroners and Funeral Directors: To perform their legally authorized duties. • Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board. • Inmates: The Practice created or received your PHI in the course of providing care. • Business Associates: To organizations that perform functions, activities or services on our behalf.

3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object Unless you object, the Practice may disclose PHI:

To your family, friends, or others if PHI directly relates to that person's involvement in your care. If it is in your best interest because you are unable to state your preference. 

4. Uses and Disclosures of PHI Based Upon Your Written Authorization

The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:

Marketing, sale of PHI, and hypnotherapy notes. 

You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above. The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing. 

OUR RESPONSIBILITIES 

• The Practice is required by law to maintain the privacy and security of PHI. 
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above.
• The Practice will inform you if PHI is compromised in a breach.

*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.* 

This Notice is effective on 01/01/2024.