Informed Consent for Nontherapeutic Hypnosis and Neurofeedback

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

    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 understand that the methods of counseling, hypnosis, and neurofeedback include relaxation, breath work, creative visualization, positive affirmation, self­-awareness development, revisiting past memories, questioning attitudes, exploring difficult sensations, and other techniques and may produce physical and emotional responses.

    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 Lincoln Stoller is obligated to report to others, any act of 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 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 counseling, hypnosis, and neurofeedback services offered by Lincoln Stoller, PhD, CHt, CCPCPr.