Release of Liability – A Little Hypnosis LLC

incontinence waiver

By completing the form below, you are requesting to begin sessions relating to incontinence. This is a major life decision, and will not progress without the completion of this form as well as the consent of your hypnotherapist. Please understand that your hypnotherapist may, at any time during the progress of the sessions, decide that this aggressive treatment is no longer in your best interest.

Please complete the form below to begin the process.

Name

Date of Birth

Incontinence Type

Your Hypnotherapist

Lead Hypnotherapist Approval

I have received approval from the Lead Hypnotherapist and have received this in writing.

Describe, in your own words, how achieving this level of incontinence would effect your life

Do you have reliable access to sanitization products needed in order to care for yourself in a safe and effective manner? (Diapers, Pads, Wipes, etc)

Is your medical doctor aware of your desire to achieve this level of incontinence?

Do you have the support of any friends, family, or caregivers?

By checking this box, you are agreeing to the following statements:

I am requesting to receive hypnosis services related to the loss of control of my bladder, bowel, or both. I understand that results are not guaranteed, and also understand that results, if obtained, may be permanent in nature.

I understand that A Little Hypnosis, LLC, it's owners, staff, and other entities are not medical professionals and may not treat, diagnose, or prescribe any treatment for a medical or mental health condition.

I acknowledge that I have considered all possibilities, including medical intervention. This is a major life decision and I have had the time to consider the implications of this intervention and am choosing to continue with this route of intervention on my own accord.

I understand that I have the right to terminate this request at any time, but the results of this work may be considered irreversible, or may take an extensive period of time to reverse. I understand this information and agree that if reversal is not possible, I understand that I may be permanently incontinent for life following this course of intervention.

Clients using A Little Hypnosis services understand that these services are not offered as a substitute for clinical mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. No member of the ALH team or staff are considered licensed medical or mental health practitioners.

I acknowledge and agree that I am fully responsible for all actions and my own well-being.

You will also understand that all comments and ideas offered by a hypnosis professional are solely for the purpose of aiding you in achieving your defined goals in order to improve or enhance your mental wellbeing or mental maintenance. You are able to give informed consent, and hereby give such consent to A Little Hypnosis, LLC to assist you in achieving such goals. Where we think it is in the interest of your well-being, we may request that you speak with a medical professional and obtain further medical review. If you choose not to do so, treatment will stop immediately.

I hereby release, waive, acquit and forever discharge A Little Hypnosis, LLC, my hypnotist, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages claimed or that I may have arising out of my own acts or omissions or acts and omissions of my hypnotist as a result of any advice given otherwise resulting from the hypnotist/subject relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made. I understand that, at any time during intervention, I have the right to terminate the hypnotist/subject relationship. As such, I also understand that A Little Hypnosis and its staff may, at any time during intervention, choose to terminate this relationship or end work toward any goal that they feel uncomfortable with.

Digital Signature - Your signature on this line will hold the same level of enforcement as a written signature.