CONSENT FORM

Last updated: Sunday, October 26, 2025 2:31 PM

 

By engaging the services of HabitsBeGone.com, you acknowledge and agree to the following:

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1. Nature of Services

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     You understand that the services provided by HabitsBeGone.com involve therapeutic hypnosis and related           wellness techniques designed to support positive behavioral, emotional, and cognitive change.

 

     You acknowledge that:

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• Hypnosis is a complementary therapeutic process and not a substitute for licensed medical, psychological, or psychiatric care.

• You are responsible for consulting with your healthcare provider before making any changes to your treatment plans or medications.

 

2. Voluntary Participation

 

       Your participation in hypnosis sessions is entirely voluntary. You may choose to stop a session at any
       time or  decline any suggestion offered during hypnosis.

     

       You also understand that individual results vary, and no specific outcomes are guaranteed.

 

3. Confidentiality and Privacy

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     All information you share during consultations or sessions will be kept strictly confidential in           accordance with professional standards and applicable privacy laws, including HIPAA (where         applicable).

 

     Exceptions to confidentiality may include:

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​     If disclosure is required by law (e.g., risk of harm to self or others, or legal subpoena).

     If you provide written consent for your information to be shared with another professional.

     Your personal and session data are protected as described in our full Privacy Policy.

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4. Data Handling and Communication

 

      You understand that:

• Records of your sessions may be stored electronically.

• Email and online communications are convenient but not always 100% secure; you may request alternative communication methods if preferred.

     

       For a fee, you may request copies of your records or ask for deletion of your data (as permitted by           law).

5. Fees and Cancellations

 

       You agree to the fees, cancellation policies, and payment procedures outlined below for Missed or

       Late or Canceled appointments.

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1. A fee of $75.00 will be charged & due at time of request for “copies of” or “deletion of your records”.
    

2. A fee equal to the session fee will be charged for cancelations with less than 24 hours notice.

3. An additional fee of $35.00 will be added as a late fee if you are more than 10 minutes late for a session.  In the case of a late arrival which does not leave sufficient time to conduct your scheduled session before my next session, you will be treated as if you were a “no show” and charged your full session rate.

    

6. Acknowledgment and Consent

 

    By signing below, you confirm that:

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• You have read, understood, and agree to the terms of this Consent to Treatment & Privacy Acknowledgment.

• You consent to receive hypnosis and related wellness services from HabitsBeGone.com.

• You understand your rights to privacy and data protection as described in our Privacy Policy.

• You understand and agree to the application of the "late or missed/cancelation" fees.

 

Date: _____________________   Client Name: _______________________________

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Signature (electronic or handwritten): ______________________________________