New Client Waiver
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Email *
Name and pronoun(s) *
Email *
Address *
Phone number *
Birthday
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Briefly describe your goals for hypnotherapy *
Emergency Contact info- name, phone, relationship
How did you hear about Calm Palm? *
"In recognition that millions of people receive a substantial volume of healthcare services from complementary and alternative health care practitioners, Louisiana Law allows access by  residents to complementary and alternative healthcare practitioners who are not providing services that require medical training and credentials. The purpose of a program of hypnotherapy is for vocational and avocational self-improvement (Business and Professions Code 2908) 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 Louisiana.  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. Palm R. Palm CHt will to the best of their 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 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. I also agree to pay Calm Palm LLC for services, in full, on the date of each session, unless otherwise agreed upon. I agree to give 24 hours notice for all cancellations or changes of scheduled appointments.  I understand that missing a scheduled appointment without prior cancellation, or canceling with less than 24 hours notice, may result in being charged a $25-$50 Cancellation Fee." *
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