Sextacular® QHHT Hypnotherapy Terms & Agreement

First Name: ______________________

Last Name: ___________________________ 

Date of Birth: ____________________

Gender:        Male   Female

Phone Home: ____________________

Mobile: ______________________________ 

E-mail: _______________________   

Occupation____________________________

Address:________________________________________________________

City: __________________State: ________________ Zip Code: ____________ 

How did you hear about Dr. Lori / QHHT? _______________________________ 

I, herewith, voluntarily agree to sign this agreement and I fully understand that Lori C. Ebert, PhD, who will lead my hypnosis, is not a medical doctor, nor has a degree in Psychiatry, and can neither diagnose nor treat any type physical or mental disorder. 

1. I am participating in this hypnosis session by my own choice because I want to be here. 
2. I understand that I am not a patient, but a partner in my hypnosis experience. 
3. I understand that any suggestion that may be made during this session is only
   informative and a part of a personal and/or educational motivation program.
4. I understand that my progress here involves how I care for myself physically,
   mentally, emotionally and spiritually.  
5. I understand that this hypnosis session is exclusively for educational or
   emotional reasons. It is not intended to be in any way used as medical or psychological advice as this can be only given by a medical professional or a mental health specialist. 
6. I understand that transformation is a process and that it can take time. _____

DISCLAIMER: Hypnosis is not intended to cure any specific condition. Dr. Lori Ebert makes absolutely no claims of a cure for any disease. Individual results may and will vary. Each session is unique and its success depends on your (the Client’s) full cooperation and participation in the entire process.

Terms & Agreement Responsibilities and Liability Release 

1. I am willing to be guided through relaxation, visual imagery, hypnosis, and meditation techniques. I am aware that these modalities are spiritual-based and non-medical in nature and it is my responsibility to consult my regular doctor about any changes in my condition or my medication. ________  🔲
2. I understand the above modalities are not substitutes for regular medical care and I have been advised to consult my regular medical doctor or health-care practitioner for treatment of any old, new or existing medical conditions. ________  🔲
3. I understand that all hypnosis is self-hypnosis. Being hypnotized does not equal being asleep. During a deep hypnotic trance, you can open your eyes, speak, laugh, walk and you may be aware of everything that happens around you. You can even open your eyes and think it is not working and are not hypnotized. However, when you allow the feelings or thoughts that come to your mind to flow freely as Dr. Lori speaks to you, you will relax and remember forgotten events in the current life or any other lives. ________  🔲
4. I understand that change is my own and complete responsibility. I understand all healing is self-healing and that Dr. Lori is only a facilitator in the process of helping me to solve my own problem(s). It is my responsibility to be open and honest, provide accurate feedback and be forthcoming with details and information that may help me achieve my outcomes. ________  🔲
5. I understand that our session will be digitally recorded for my later use and that Dr. Lori retains the copyright of these recordings. I also understand that with these types of metaphysical sessions, the energy in the room can affect the equipment and recording resulting in static or blank recordings. ________  🔲
6. I understand that often in hypnosis sessions, universal information is provided through the client to the benefit all of humanity and mankind. I agree to allow Dr. Lori to share this information and any accompanying story either on video or in written form in blogs or books as long as my first and/or last name and all personal and relevant details are omitted and/or changed. (you will choose how you wish the video to be presented) ________  🔲

I am of legal age and understand that I am entering into a cooperative relationship of my own free will. I accept that I am a willing participant in this cooperative relationship that will employ hypnosis techniques, regression and any other appropriate modality by Dr. Lori. Therefore, I do hereby release and discharge Dr. Lori from any claims of damages, copyright, demands or actions whatsoever in any matter arising from or growing out of my cooperative participation. Any concerns or questions can be addressed with the Quantum Healing Hypnosis Technique Accredited Training Provider as the credentialing body. I have received and read this Client Information and Agreement Form and understand what I have read: 

Client Signature: _______________________________

Date:_______________________

I, Dr. Lori, am trained as a QHHT® Practitioner as taught by Dolores Cannon. I am also a Health Educator with a Doctorate Degree in Health Education from Colorado State University. I do regular continuing education to maintain and further develop my training at the high level. I commit to you that I will utilize all my skills and experience to assist you on your spiritual journey of service, forgiveness, compassion and love. You have my assurance of my full commitment, integrity, professionalism, confidentiality and respect. All sales are final and no refunds will be given.