When is the best time for us me contact you? 

May I contact your doctor as to your progress?  Yes   No

How did you hear about our service?

ALL INFORMATION IS STRICTLY CONFIDENTIAL

Confidentiality - No information pertaining to you will ever be released.  I will not release any information to any person without a written authorization from you except as provided by law.
 

Theta State Therapy (TST) - Is a therapy term coined by myself and is conceptualized from a combination of my training in hypnotherapy, NLP (Neuro-Linguistic Programming), and psychology techniques.  It is a series of conversations between myself and my client.  It is based on the theta brain wave state, relaxation, imagery, memory, and emotion to elicit permanent change.  Theta state therapy, hypnotherapy, and NLP are not at this time licensed by state governments.  I am neither a physician nor a licensed health care provider and I do not provide medical diagnosis or medical treatment for illness, disease, or mental disorders.

Spontaneous Abreaction:  After conducting literally thousands of sessions I have never had anyone go into a spontaneous abreaction.  This can happen when the brainwaves are slowing down in the beginning of a session.  A person can automatically, mentally, find themselves reliving another situation.  These situations are generally negative events that have happened in the past.  For example:  One of my instructors was in session when his client was all of a sudden storming Normandy Beach in WWII.  This seemed real to the person.  An abreaction happens without the therapist instructing the person to go to any particular event.  The event is something that the subconscious mind feels it needs to deal with, so it goes there spontaneously.  If this happens the therapist instructs the person to allow the scene to fade and tend to their breathing.  After this statement is repeated the person comes back to the current time in a relaxed state and the session proceeds.

   To my knowledge no one has ever been harmed by going into an abreaction, in fact myself and many other therapists use something called "abreactive age regression."  This is the building of a negative emotion to track it back to its source.  Again, I have never, not once, had any of my clients go into a spontaneous abreaction but it is possible.

   If this concerns you let us discuss your concerns.  If you are overly worried about this then perhaps this type of therapy is not for you.  By electronically signing this form, through submittal, you are now agreeing to NOT hold myself, Tim Bartley, or Renaissance Alternative Health Center responsible in any way if you do indeed experience a spontaneous abreaction during a session.

Cancellation / Truancy / Adjusted Fee Policies

- Being on time & “No shows” (absenteeism)

          o I require 48 hour notice for cancellation & rescheduling.
          o I book up to 5 sessions per day, being late or “no shows” greatly affects my schedule.

A regular session charge of $125 will be billed if you are a "no show" or have not given 48 hour notice.

If you are 15 minutes or more late I reserve the right to not hold the session & charge $35.  (This offsets my entire schedule for all clients after you)

Renaissance can, at its discretion, permanently refuse services if any of the follow occur:

- If 2 appointments are missed without 48 hour notice
- You are 15 minutes late twice or more
- You cancel/reschedule multiple appointments

Attempted Session / Fee Adjustments

  All of my clients do not follow directions or they think through the process which destroys the process.  If this occurs a $35 fee is charged for the attempted session and the program fee is waved until a point in time when we are successful.  (A conditioning audio CD will be provided to you at no cost.)  This scenario is solely determined by Renaissance Alternative Health Center.

Refunds

  I do not issue refunds under any circumstances.  Once I enter into this contract I am bound to its terms and must pay for the session(s) at time of service. I agree to pay court costs and attorney fees if I am late in paying for or do not pay for said treatment and Renaissance deems collection procedures are necessary.

Medication Note

- If you are currently taking medication that makes you sleepy or unfocused we would ask that
  you abstain from taking medication 24 hours before our sessions if possible.

- Do NOT stop or abstain from taking your medication without first speaking with your doctor.

Liability Release / Electronic Signature

  I fully understand that Theta State Therapy/Hypnotherapy/NLP is a mental conditioning process that will allow me to use the natural faculties of my mind to create desired and positive change and health in my life.  I understand this approach is complementary to and not a substitute for medical care by a physician.  I therefore release Tim Bartley and Renaissance Alternative Health Center from any liabilities for any change in my physical, mental, or emotional state before, during, or after treatment including if I experience a spontaneous abreaction.

 

By clicking on submit below I understand that I am legally giving my consent to all of the provisions of this: Client History, Consent, & Contract Agreement form.


(Submission of this form acts as your legal signature)