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I agree to engage in the process of nontherapeutic hypnosis and neurofeedback. I understand that I will have all choices at all times and can start and end the process at anytime, even during my session. These services offered as non­therapeutic hypnotism and neurofeedback, defined as the learning of self-­hypnosis and neurofeedback to induce positive thinking, create commitment to change and to learn the techniques of self-­hypnosis and neurofeedback to produce self­-control over physical experiences and emotional awareness.

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

I agree to continue medication as prescribed by my attending physicians, if any, 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 whatever medication has been 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 understand Lincoln Stoller is obligated to report to others, any act of abuse to children, the disabled, or the elderly.

I understand confidence may be breached if I disclose abuse to children, the disabled, or the elderly.

I understand Lincoln Stoller is obligated to provide my confidential material to legal authorities if this information is subpoenaed by a court of law.

I understand confidence may be breached if confidential materials are subpoenaed by the court.

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.

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You must click the following Acceptance check box in order to complete this form.
I have read and agree to the terms and conditions above.

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