Your Name (required)

I agree to engage in the process of counseling, 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 counseling, non­therapeutic hypnosis, and neurofeedback, defined as reframing, 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 counseling, 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.

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 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 the methods of counseling, 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 counseling, hypnosis, and neurofeedback services offered by Lincoln Stoller, PhD, CHt, CCPCPr.

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

Signed (please type your name once more, required)

Your Email (required)

Date (required)

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.

Δ