Hypnosis Associates of Central Florida

120 West State Road 434, Winter Springs, FL 32708

Phone: 407-971-0041, Email: Info@hypnocfl.com

Confidential Personal Information

 

 

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First Name                                         MI        Last Name   

 

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Address:

 

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City                                                                                         State               Zip

 

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Home Phone                         Cell Phone                             Work Phone                 

 

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E-mail Address

 

Would you like to receive e-mail information from Hypnosis Associates of Central Florida?  Yes                 No

 

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Date of Birth:                        

 

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Occupation:

 

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How did you hear about Hypnosis Associates of Central Florida?        

 

Reason for this consultation:

 

 

 

Other areas of interest:  (Please circle any which apply)

 

Weight Loss                  Stop Smoking               Fear of Flying                Concentration 

Creativity Enhancement                          Self Esteem                  Past Life Regression 


Forgiveness           Phobias                         Relationships          Shyness           Shame

  
 Relaxation          Anger              Motivation                  Depression                    Insecurity    
      
Sports Performance        Abuse              Finding Lost Objects        Childbirth          Insomnia 

      
Eating Disorders             Substance Abuse            Healing             Auditions         

 
Public Speaking             Confidence                  Hang-Ups           Dental Procedures
 
                  Hair Pulling                    Grief                            Test Anxiety

 

Areas you may wish to improve: (not listed above)   

 

 

 

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__________________________________________________________________________Name of primary care physician:   

 

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Address of primary care physician:           

 

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Phone number of primary care physician: 

 

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Please list any medication you are currently taking:

 

 

Please note any treatment you are currently receiving from ANY health care provider:  

 

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Pursuant to Florida Business and Professional Code, we, Hypnosis Associates of Central Florida, make the following disclosures: We are professionals who provide services that are alternative and complementary to the healing arts services licensed by the state. Each client will be interviewed and if it is determined that the services we provide can be of benefit, we will provide those services in accordance with the education, training, and experience we have.

 

We offer the following services:

 

1. Hypnosis- This is a re-programming of the thought processes. It is accomplished by providing the atmosphere for the client to move into subconscious awareness states such as alpha, theta, and delta. The theory is that in these states the mind is more suggestible so that suggestions are more likely to be accepted by the mind.
2. NLP (Neuro Linguistic Programming) – This is a Pavlovian behavioral model based on the idea of creating new, more helpful associations for the client. It is non-hypnotic. The theory is that if one can form new associations to existing behavior, that behavior can be modified in a positive way.

 

These services are not licensed by the state. The services do not include the practice of medicine or psychology or any other healing art, since we are not licensed physicians.

It is your responsibility to inform your physician that you are seeing Hypnosis Associates of Central Florida for hypnotherapy. It is assumed by you signing this release that you have either notified your physician that you are seeing a hypnotherapist for treatment or that you have elected not to inform your physician at this time.

 

We have the following education, training, experience and other qualifications regarding the services provided:

 

Over twelve years of hypnosis experience

Member of the American Alliance of Hypnotists

Member of the Sound Healers Association

Member of the National Guild of Hypnotists

Member of the International Hypnosis Association

 

I, (please print your name) ___________________________, hereby acknowledge that I have been provided with the above information, have read such, and have received a copy of this disclosure.

 

 

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Client Signature                                                                                            Date               

 

 

 

 

 

 

 

 

 

 

 

NAME: ____________________________________

NOTICE OF PRIVACY PRACTICES:

HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

 

My signature below indicates that I have been provided with a copy of this Notice of Privacy Practices.

 

Signature of client: ­ ___________________________________

 

Date: ______________________________________________

 

Understanding Your Health Record/Information

 

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.

 

This information, often referred to as your health or medical record, serves as a:

. Basis for planning your care and treatment;

. Means of communication among the many health professionals who contribute to your care;

. Legal document describing the cart: you received;

. Means by which you or a third party payer can verify that services billed were actually provided;

. Tool in educating heath professionals;

. Source of data for medical research;

. Source of information for public health officials charged with improving the health of the nation;

. Source of data for facility planning and tool with which we can assess and work to improve the care we render and the outcomes we achieve.

 

This Notice describes how health information about you as a patient of this practice may be used and disclosed, and how you can get access to your health information. We reserve the right to change this Notice in the future.

 

Your Health Information Rights:

 

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

 

.  Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522

.  Obtain a paper copy of this Notice

.  Inspect and obtain a copy your health record as provided for in 45 CFR 164.524. You must submit your request in writing. We are entitled to charge a copying fee for this service.

.  Ask us to amend your health record as provided in 45 CFR 164.528. Your signature and explanation are required.

.  Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528

. Revoke your authorization to use or disclose health information except to the extent that action has   already been taken.

 

If you have questions or would like additional information, you may contact the Director of Health Information Management. If you believe your privacy rights have been violated, please discuss it with me. You can file a complaint with the Director of Health Information Management or with the Secretary of Health and Human Services. There will be no penalty for filing a complaint.

Our Commitment

 

We are committed to maintain the privacy of your health infom1ation, as required by law. We will not use or disclose your health information without you_ authorization, except as described in this notice.

 

Examples of Disclosures for Treatment, Payment and Health Operations

We will use your health information for treatment within our practice. With your consent, we will also provide your outside physician or a subsequent healthcare provider with copies of various reports that should assist him/her in treating you as well.

 

We will use your health information for payment. For example: To obtain insurance benefits for you, forms may include information that identifies you, as well as your diagnosis, procedures and supplies used.

 

 

We may use your health information in an effort to continually improve the quality and effectiveness of the healthcare and services we provide.

 

Outside Medical Services:

We may disclose your health information to other providers so that they can perform the job we've asked them to do, and so that they can bill you or your third party payer for services rendered. So that your health information is protected, however, we require these providers to appropriately safeguard your information.

 

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for you, care, your location, and general condition.

 

Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

 

Other: We may disclose health information to funeral directors, organ procurement organizations, correctional institutions, public health authorities, workers compensation programs, law enforcement, and/or the Food and Drug Administration consistent with applicable law to carry out their duties.

 

Legal Proceedings: Your health record may be subpoenaed through the legal system.

 

Public Health and Safety: We may provide medical information about you if required by law, or to prevent serious threat to public health and safety.

 

Research: We may disclose information to researchers when their research has been approved by an Institutional Review Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

 

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinica1 standards and are potentially endangering one or more patients, workers or the public.

 

 

CANCELLATION/ RESCHEDULE POLICY

 

 

NAME: ____________________________________

 

 

 

     A 24 hour notice is required for all cancellations or rescheduled appointments. If our office is not notified of a change prior to 24 hours before your appointment, you will be charged the full price of your session.

   If you reschedule the same appointment more than once, you will be charged double for that session.

   These fees will be charged to your credit card if we have one on file, otherwise they will be billed to your mailing address and due upon receipt.

    By signing below, you acknowledge an understanding of the above policies and agree to be subject to them.

 

 

 

 

Signature________________________  Date __________