SucceSSwork nLP & HyPnoSiS

Date:__________________________________ Client History Name:_______________________________­ _____­E-mail:____________________________________ _ ­ Address:_________________________________City:___________________State:_______Zip:_______ Home­phone:(___)___________Work­phone:(___)_________Date­of­birth:___/___/_____­Age____Sex__ Marital­status_____________ Referral:­Name:_____________________________Other:______________________________________ Has­anyone­ever­attempted­to­hypnotize­you?­Yes□No□Who?:____________Reason:________________ Do­you­believe­you­were­hypnotized?­Yes□No□Why?:__________________________________________ Medical History Have­you­ever­been­treated­for­an­emotional­problem?­Yes□No□ If­yes,­are­you­currently­receiving­treatment­or­counseling?­Yes□No□ Are­you­currently­taking­any­psychiatric­medications?­Yes□No□­ Reason­you­are­coming­for­hypnosis:_______________________________________________________ Any­previous­efforts­to­solve­problem? Yes□No□Results:_______________________________________________________________________ Are­you­currently­undergoing­medical­or­psychological­treatment­for­the­above­problem?­Yes□No□ Where?:­_________________________­Doctor’s­name________________________________________ Do­have­any­questions­about­hypnosis?­Yes□No□­­What­are­they?:______________________________ ____________________________________________________________________________________

Signature­(If­client­is­a­minor­a­parent­or­guardian­must­sign)

Please­note­that­all­sessions­are­recorded­for­your­protection.­These­records­are­purely­for­internal­record keeping­and­will­never­be­used­for­any­other­purpose­without­your­express­permission.­

www.SucceSSwork.info

1-917-860-0734

Jeff@SucceSSwork.info

SucceSSwork nLP & HyPnoSiS
Client’s Bill of Rights Under­New­York­State­law,­an­unlicensed­complementary­and­alternative­health­care­practitioner­may­not­provide­a­medical­diagnosis or­recommend­discontinuance­of­medically­prescribed­treatments.­If­a­client­desires­a­diagnosis­from­a­licensed­physician,­chiropractor, or­acupuncture­practitioner,­or­services­from­a­physician,­chiropractor,­nurse,­osteopath,­physical­therapist,­dietitian,­nutritionist, acupuncture­practitioner,­athletic­trainer,­or­any­other­type­of­health­care­provider,­the­client­may­seek­such­services­at­any­time. 1. I,­Jeff­Sauber,­am­a­sole­provider­of­services,­and­therefore­have­no­supervisor.­Any­complaints­about­services­received­should be­filed­directly­with­me­using­the­contact­information­provided. 2. Fees­for­services­rendered: Initial­appointment:­$150.­Appointment­generally­lasts­1­1/2­hours Successive­appointments:­$100­hour Hypnosis­Spa­Sessions:­$75­for­45­minutes On­occasion,­I­will­negotiate­to­accept­partial­payment,­or­at­my­discretion,­waive­payment,­based­on­individual­client­circumstances.­ The­client­must­cancel­appointments­with­a­minimum­of­24­hour­notice,­or­still­be­responsible­for­the­appointment­fee­in­full. Currently,­I­know­of­no­specific­insurance­companies­that­accept­claims­for­the­services­offered­in­this­office.­On­occasion,­certain employer­insurance­plans­have­accepted­receipts­for­services­rendered­and­reimbursed­the­client.­If­you­believe­that­you­may­be eligible­for­reimbursement,­I­will­gladly­produce­a­receipt­for­services­rendered­and­the­amount­paid­for­them. I­do­not­accept­Medicare,­medical­assistance­or­general­assistance­medical­care. The­above­fees­are­subject­to­change­at­any­time­with­30-day­notice. I,­Jeff­Sauber,­retain­the­right­to­discontinue­service­to­anyone­at­any­time. 3. The­client­has­the­right­to­current­and­complete­information­regarding­any­assessment­and­recommended­service(s)­that­is­to­be provided­in­this­office,­including­the­expected­duration­of­the­service(s)­to­be­provided.­ 4. The­client­may­expect­courteous­treatment,­free­from­verbal,­physical­or­sexual­abuse­by­me,­Jeff­Sauber. 5. Client­records­and­transactions­that­result­from­services­provided­by­me,­Jeff­Sauber,­are­confidential,­unless­release­of­these records­is­authorized­in­writing­by­the­client,­or­otherwise­provided­by­law. 6. The­client­is­entitled­to­have­access­to­records­and­written­information­from­services­rendered­by­me,­Jeff­Sauber. 7. The­client­should­be­aware­that­a­plethora­of­health­care­services­are­available­from­other­practitioners­in­the­immediate­area. These­include,­but­are­not­limited­to:­traditional­medical­treatment,­chiropractic,­acupuncture­and­massage.­Information­about­other complementary­and­alternative­health­care­practices­and­practitioners­is­generally­available­through­freely­distributed­papers­and magazines­through­local­health­food­stores­and­dispensers.­ 8. The­client­maintains­the­right­to­choose­freely­among­available­practitioners­and­change­practitioners­after­services­have­begun, within­the­limitations­of­any­health­programs­that­the­client­may­be­involved­with. 9. The­client­has­the­right­to­a­coordinated­transfer­of­practitioners­if­a­change­of­provider­of­health­insurance­services­or­programs is­relevant­and­necessary. 10. The­client­has­the­right­to­refuse­services­or­treatment,­unless­otherwise­provided­by­law. 11. The­above­rights­of­the­client­may­be­asserted­by­the­client­without­retaliation.­ I­acknowledge­that­I­have­received,­read­and­understand­the­above­Client­Bill­of­Rights.­ __________________________________________ Signature­of­client: ____________________________ Date

www.SucceSSwork.info

1-917-860-0734

Jeff@SucceSSwork.info