Signature Required Prior to Scheduled Appointment

ELSEN HYPNOTHERAPY, Certified Regression Therapists

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 Hypnotherapists and Certified Regression Therapists, a non-refundable 50% deposit fee of $360 per Regression session at the time of booking, plus $360 on the day of the session, totaling $720. I agree to pay, in full, for your services on the date of the LBL session this $720.

I agree that deposits are non-refundable. I understand that missing a scheduled appointment without prior cancellation, or with cancellation less than 7 days before the scheduled session, will be charged to me at the current full rate, understanding that Elsen Hypnotherapy has overhead costs (offices/travel/reservations etc.) that usually cannot be canceled on short notice.

I understand that the program of conditioning offered by you for the fees described above will include one regression 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 the sessions. I claim no refund accordingly or hold Elsen Hypnotherapy responsible in any way, including financially, legally, or otherwise. I, therefore, understand that I will be paying $720 for the session, regardless of 'results', understanding that the regression process is equally applied to all clients without variations, and that difference in results, therefore, are the result of my mind, and not the process Elsen Hypnotherapy is applying. I also agree to allow Elsen Hypnotherapy in its capacity as a therapist to touch my arm, shoulder for the purpose of establishing hypnotic anchors required as deepening techniques for my session.



Whereas, Elsen Hypnotherapy is engaged in REGRESSION SESSIONS and

Whereas, I, the undersigned, am appearing on the audio recording of the regression session, and

Whereas, I understand that my voice and name will be recorded by various mechanical and electrical means of all descriptions (such recordings, any piece thereof, the contents therein and all reproductions thereof, along with the utilization of my name, shall be collectively referred to herein as the "Released Subject Matter"),

Therefore, without claiming any reward or compensation, monetary or otherwise, now or hereafter, I hereby freely and without restraint consent to and give unto the Producer and its agents or assigns or anyone authorized by the Producer, (collectively referred to herein as the "Releasees") the unrestrained right in perpetuity to own the Released Subject Matter, all of the foregoing to be without limitation of any kind. I hereby stipulate that the Released Subject Matter is the property of the Producer (the recording will not be utilized without permission from the client).

I hereby waive to the fullest extent that I may lawfully do so, any causes of action in law or equity I may have or may hereafter acquire against the Releasees or any of them for libel, slander, invasion of privacy, copyright or trademark violation, right of publicity, or false light arising out of or in connection with the utilization by the Releasees or another of the Released Subject Matter.

It is my intention not to claim any reward or compensation, monetary or otherwise, now or hereafter, in connection with any and all usages of the Released Subject Matter. I expressly stipulate that the Releasees may utilize the Released Subject Matter or not as they choose in their sole discretion without affecting the validity of this Release. This Release shall be governed by US Federal Law.

I also agree to keep confidential the contents of this session, as well as the regression 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 receive a copy of the recording of the session, starting from the point of Age 12 of the age regression from 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.


COVID-19 Liability Release Waiver

Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Elsen Hypnotherapy 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 to each statement above and release Pieter Elsen from any and all liability for the unintentional exposure or harm due to COVID-19.



*Pieter Elsen / Jenna Iantorno-Elsen

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