Signature Required Prior to Scheduled Appointment

ELSEN Hypnotherapy, Certified Clinical Hypnotherapists

Acknowledgment of Services and Fees: Subject: Self Improvement Program

I, the undersigned, acknowledge that I understand and agree to the following:

I agree to pay Elsen Hypnotherapy*, Certified Clinical Hypnotherapist, a fee of $165 per 1-hour session. I agree to pay, in full, for your services on the date of the session.

I understand that missing a scheduled appointment without prior cancellation, or with cancellation less than 48 hours before the scheduled session, will be charged to me at the current full rate.

I understand that the program of conditioning offered by you for the fees described above will include one 1-hour session only. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professional Code 2908). I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of Elsen Hypnotherapy’s sessions. I claim no refund accordingly or hold Elsen Hypnotherapy responsible in any way, including financially, legally, or otherwise. I also agree to allow Elsen Hypnotherapy in his capacity as a therapist(s) to touch my arm, shoulder for the purpose of establishing hypnotic anchors required as deepening techniques for my session.

*

(Initial)

I also agree to keep confidential the contents of this session, as well as the script used during the session and agree not to share, utilize, distribute, use for personal gain or otherwise the materials and techniques used during the session, being hereby informed the materials/scripts/techniques are copyrighted and protected by Elsen Hypnotherapy. I will NOT record the session secretly during the meeting with for example a recorder or on my cell phone.

I hereby certify that I am over the age of eighteen and that I have read, understood, and agreed to the foregoing.

*

(initial)

COVID-19 Liability Release Waiver

Due to the 2019-2021 outbreak of the novel Coronavirus (COVID-19), Pieter Elsen is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance CDC Professional and Occupational Regulation guidance.

Symptoms of COVID-19 include:

  • Fever
  • Fatigue
  • Dry Cough
  • Difficulty Breathing

I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS. I understand that Elsen Hypnotherapy cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client. All surfaces will be wiped thoroughly with hospital grade disinfectant before and after each client according to the manufacturer's directions

By signing below, I agree with each statement above and release Elsen Hypnotherapy from any and all liability for the unintentional exposure or harm due to COVID-19.

*

(Signature)


*Pieter Elsen / Jenna Iantorno Elsen

By clicking Sign & Send below you agree to the terms contained herein, and that terms are binding in your jurisdiction as defined in our Electronic Signature Disclosure & Consent

E-Sign Act Disclosure and Agreement

Your Consent To Use Electronic Records and Electronic Signatures

This website has elected to use electronic signatures as the default choice in lieu of paper. Be advised that according to the U.S. Federal E-SIGN Act in addition to various state laws an electronic signature is legally the same as a paper and ink signature. Also be advised in event enforcement is needed, all signatures are held in trust by SwiftSignature.com, as a neutral 3rd party, and may be legally enforced in court of law as per the terms of your respective contract.

Federal law requires certain safeguards to ensure that both consumers and vendors have the capability to receive copies of documents upon signature and are advised of the consequences of agreeing to receive documents electronically. Federal law also requires your consent to use e-mail and electronic versions of said contract and/or agreements, disclosures, and other documents and records, herein referred to as simply "electronic documents" that would otherwise be legally binding only if provided to you on paper as a printed physical document.

Electronic Documents for purpose of this disclosure include any documents signed using the Swift Signature service. All documents once signed cannot be revoked or canceled and will be stored for a minimum period of ten (10) years, and are available to either party at any time through our electronic web portal.

Free Document Storage Account

All signors are automatically entitled to a free document storage account within Swift Signature, the cost of which is given to you by the owner of this website. After signature, you may follow the prompts to save your document to your free account, where it will be accessible for a minumum of 10 years. This account is optional and available as a courtesy to you.

Right to withdraw consent

Note you do have the right to withdraw your consent to receive and/or use electronic documents, but be advised this does not cancel or revoke any prior documents for which permission existed at that time. The legal validity and enforcement of electronic documents, signatures, and deliveries used prior to revocation of consent will not be affected. To withdraw your consent, please contact the owner of this website.

Right to receive paper document

You have the right to have any document in paper form, should you choose at no charge to you. To request paper documents, please contact the party who referred you to this service.

By clicking "Sign and Send" on any document posting to SwiftCloud servers, you are agreeing to the terms contained herein, and are providing your consent to the use of electronic documents and signatures, as well as e-mail or sms phone message delivery of related electronic documents. You are also acknowledging receipt of this disclosure.

Hardware & Software Requirements

Use of this Service Requirements

  1. Connection to the internet
  2. Any internet web browser with graphical interface and a pointing device, aka "a mouse" for desktop computers or a touch screen for tablets or modern phones common after 2004
  3. a PDF reader or browser capable of displaying Adobe PDF documents
  4. A printer, should you wish to print and retain a paper copy of signed documents.

Acknowledgement of your access and consent to electronic records and electronic signature

By clicking "Sign & Send" on any document posting to this service, you agree that

  • You were able to read this E-SIGN Act Disclosure & Agreement
  • Should you desire, you were able to print on paper or electronically save this agreement for future reference
  • You have an active email on file with the owner of this website
  • That the device on which you indicated your agreement or signature, including both your hardware and your software comply with the terms above and were able to render the agreement in a fashion functionally equivalent to paper, and that the document agreed to was both readable and understandable.
  • That any indication of signature and/or initials in addition to information provided is wholly yours and subject to the terms above.
  • You consent to receive electronically any records, notices, agreements or disclosures made to you by our client, the referring service, during the course of your relationship with that company, subject to revocation per terms above.

Electronic Signature         Disclosure & Consent

Privacy & Cookies

This site uses cookies. By continuing to use this website, you agree to their use. To find out more, including how to control cookies, see here Cookie Policy

Accept Decline