Informed Consent Form Page2018-04-26T16:19:47+00:00

Informed Consent for Nontherapeutic Hypnosis and Neurofeedback

I agree to engage in the process of nontherapeutic hypnosis and neurofeedback.

I agree to continue medication as prescribed by my attending physicians and understand that hypnotherapy and neurofeedback are not substitutes for medical care. I understand hypnosis and neurofeedback offer tools of self­-discovery, self-regulation, and awareness. Hypnosis and neurofeedback neither diagnose nor treat any medical or mental health condition.

I agree to continue medication as prescribed.

If any medical symptoms progress or become acute I agree to seek medical attention from a licensed healthcare provider. In the event of a medical emergency or if I feel suicidal I will call 911 or other emergency help.

I agree to seek medical attention if medical symptoms progress.

I understand that the methods of hypnosis and neurofeedback include relaxation, breath work, creative visualization, positive affirmation, self­-awareness development and other techniques and may produce physical and emotional responses.

I understand the methods of hypnosis and neurofeedback include those listed.

I understand Lincoln Stoller is obligated to report to others, and act to prevent, any actual or potentially serious injury to myself or others.

I understand confidence may be breached to insure the safety of myself and others.

I agree to inform Lincoln Stoller, PhD, CHt of any adverse feelings or experiences related to this process, at the time of my awareness of them. I am over age 18, and consent to hypnosis and neurofeedback services offered by Lincoln Stoller, PhD, CHt.

I agree to inform Lincoln Stoller of any adverse feelings or experiences.