STATEMENTS OF DISCLOSURE AND UNDERSTANDING

Confidentiality:  

Confidentiality will be strictly maintained except for the following circumstances:  (1) with your permission and a signed release of information to a particular person or agency.  (2) By law, any report of physical, sexual abuse, or neglect of a minor, spouse, or an elderly person.  (3) If I have reason to assume that you may harm yourself or another person. Also, I use a cell phone so that I am accessible, which cannot be considered 100% secure.

Payment for Services:

Payments are to be made prior to or immediately following each session. Insurance carriers in the State of Idaho do not, as a practice, cover these therapy sessions. I understand that I am personally responsible for payments.

Cancellation of appointments:

On occasion, a situation may arise which prevents you from keeping your scheduled appointment. Please notify me 24 hours in advance of your appointment if you cannot keep it. Except in emergency situations, you will be expected to pay for any sessions that you miss without this advanced notice. If you cannot provide 24 hours advance notice, you have purchased the time as it was reserved for you, and will be billed accordingly.  

➢ I have received, read, and understand the statements of disclosure.

➢ I have been informed of the terms of confidentiality and agree to them as stated above.

➢ I agree to pay for each session at time of service.

➢ I have read the above information, and understand that I am encouraged to ask questions, and give input regarding the hypnotherapy process at any time.  If there is anything in this form that I do not understand, it is my responsibility to seek clarification.

We reserve the right to refuse hypnosis and hypnotherapy services and training to anyone. We do not work with drug addictions, alcoholism, and diagnosed mental illness disorders where prohibited by state laws.

I understand that if I am currently working with a medical or mental health care provider and have been diagnosed with a medical or mental health disorder, and/or I am taking prescription drugs for the disorder, and should I want to work on a behavioral modification issue with hypnotherapy, I am responsible to inform my mental health care provider, and the doctor who may be prescribing any medications, and explain to them what I am considering doing with hypnotherapy for behavioral modification.


We prefer that you bring us a prescription from your mental health care provider and the doctor who is prescribing your medicine prescriptions to have us work with you for behavioral modifications with hypnotherapy, so they are always informed of what you are doing. If they have any questions, please direct them to the website: LRHypnotherapy.com or have them contact Lige to answer questions or address concerns: PHONE: (208) 317-2978.  These procedures are standard operating practice and are accomplished on a routine basis.

I have registered to attend hypnosis, self-hypnosis, and hypnotherapy individual or group sessions of hypnotherapy and training with Lige Rose. I STATE AND UNDERSTAND THAT I HAVE BEEN DULY ADVISED AND INFORMED THAT HYPNOTHERAPY SESSIONS DONE IN INDIVIDUALLY AND/OR GROUP SETTINGS, COULD BE A VERY INTENSE PERSONAL EXPERIENCE, AND I UNDERSTAND AND WARRANT THAT I AM PHYSICALLY, MENTALLY, AND EMOTIONALLY CAPABLE TO ATTEND THE HYPNOTHERAPY SESSIONS AND/OR SELF-HYPNOSIS TRAINING WORKSHOPS.