Client Registration Form

  • PLEASE CAREFULLY READ AND COMPLETE THE QUESTIONS ON THE FOLLOWING FOUR PAGES. PLEASE BE BRIEF. THIS SHOULD TAKE A MAXIMUM OF 10-15 MINUTES.

    I am requesting Clinical/Medical Hypnosis, Neuro-Linguistic Programming (NLP) and/or Life Coaching services with Dave Berman, C.Ht. By submitting this Client Registration Form I hereby authorize him to coach and/or hypnotize me for the purposes outlined in the form, and for any other future purposes I may request. I understand that results vary and that Dave Berman may not guarantee results.

    I acknowledge that Dave Berman, C.Ht. is not a licensed medical doctor or therapist. I understand that Hypnosis, Coaching and NLP are complementary care and not a replacement for medical treatment, psychological or psychiatric services or counseling. I understand that Dave Berman, C.Ht. does not treat, prescribe for or diagnose any condition. I understand that as a facilitator of Hypnosis, Coaching and NLP, Dave Berman, C.Ht. is not practicing any other profession that requires a license.

    I certify that my participation is of my own free will and I accept complete responsibility for my well being at all times. If I am being prescribed medication or otherwise receiving medical treatment for any issue related to these sessions, I will request a written doctor's referral to Dave Berman, C.Ht.

    I am aware and understand that in some cases it may be necessary for Dave Berman, C.Ht. to respectfully touch my shoulder(s), hand, wrist, or knee(s) in order to assist me. I give Dave Berman, C.Ht. permission and consent to do so in order to help me most effectively.

    I am determined to achieve my goals and committed to practicing techniques or otherwise doing assignments given to me by Dave Berman, C.Ht.

    I understand that all services rendered to me are to be paid in full at the time of each session and that I am required to give Dave Berman, C.Ht. a minimum of 24 hours notice in the event of a cancellation. I understand if I fail to comply, I will be responsible for paying the amount of service scheduled. I also take responsibility for being on time for my appointment, and will be charged for the full scheduled appointment time. I have been advised that I am free to terminate any or all sessions at any time.

    I acknowledge the Privacy Policy of Dave Berman, C.Ht. assures strict confidentiality of the information I will provide below, in our sessions, and any other communication between us, except: information I specifically ask him in writing to release to an agency or individual; child abuse; elder abuse; if I pose an imminent danger to myself or others; or in the case of subpoena of records. I also understand that he may consult with other colleagues on occasion, but in this circumstance, clients are not identified by name.

    I agree to release and hold harmless Dave Berman, C.Ht. from any claim arising out of any portion of these sessions in which I am voluntarily participating, including any claim for physical and/or mental injury to myself, whether caused by negligence or otherwise.

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Verification

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