Cliënt information and agreement form Full out this form before the day of your session Session date* Day Month Year Name* Name Last name Date of birth* Day Month Year Age*Gender* Female male MaritaI status* Occupation* Number of children*Have you ever been hypnotized before* Yes No The reason for your Hypnosis session*Information & AgreementI voluntarily agree with this agreement and acknowledge the risks because I understand that Sandra Akkermans who will perform the hypnosis, is not a doctor, does not have a diploma in psychiatry and cannot establish a diagnosis of physical or mental disorder. Information 1. I am participating in hypnosis by my own choice because l want to be here. 2 I understand that I am not a patient, i am participant in my own hypnosis experience. 3. I understand that any suggestion made during this session is only a part of a personal and educational motivational program, and is only informative. 4. I understand that my progress here invoIves how I care for myself physically, mentally, emtionally and spiritually. 5. I understand that this hypnosis session is excIusively for educationaI and/or emotional reasons. It is not intended to be in any way used as medical or psychoiogicaI advice, this can onIy be given by a medical professional or a mental heaIth specialist,It is not intended that this be used in any way as medical or psychological advice. This advice can only be given by medical professionals or a specialist in mental health. 6. I understand that transformation is a process and it can take time. * DISCLAIMER: Hypnosis is not intended to cure any specific condition. Sandra Akkermans claims in no way to offer a cure for a condition or disease. Individual results may differ. Every session is unique and its success depends on my (the cliënt’s) coöperation and trust in the process. Agreement 1 I am willing to be guided by relaxation exercises, visualization, and other hypnosis techniques. I am aware that these modalities are spiritualbased and non-medicai in nature and it is my responsibiliy to consuIt my regular doctor about any changes in my condition or changes in my medication. 2 I understand the above modalities are not substitutes for regular medical care and l have been advised to consuIt my regular medicaI doctor or heaIth-Care PraCtitioner for treatment of any old, new or existing medical conditions. 3. I understand that being hypnotized is not being asIeep. During a deep hypnotic trance, you can open your eyes, speak, laugh, walk and you may be aware of everything that happens around you. You can even open your eyes and think it is not working and are not hypnotized, but when you allow those feelings or thoughts that come to your mind to flow freely as Sandra Akkermans speaks to you, you will be relaxed and remember forgotten events in this life or a past life. 4 I understand that change is my own and compIete responsibiIity. l understand all healing is self-healing and that Sandra Akkermans is only a facilitatior in the process of helping me to solve my own problems. 5 I understand that our session will be digitally recorded for my Iater use and that and Sandra Akkermans retains the copyright ofthese recordings. I also understand that in these types of metaphysicaI sessions, the energy in the room can affect the equipment and recording resuiting in static or blank recordings. 6. I understand that often in Hypnosis sessions, Universal information is provided through the cliënt to benefit all of humanity. I agree to alIow Sandra Akkermans to share this information and any accompanying story either on video or in written form in blogs or books as long as my first and/or last name and any personal and relevant detaiis are omitted and/or changed. (On videos, you agree on what to omit.) I am of legal age and understand l am entering into a coöperative relationship of my own free will. I accept that l am a willng participant in this coöperative relationship that will empIoy hypnotic techniques, and any other appropriate modality by Sandra Akkermans, therefore, l do hereby release and discharge Sandra Akkermans from all claims of damages, copyright, demands or actions whatsoever in any manner arising from or growing out of my coöperative participation. Sandra Akkermans is a certified QHHT and Introspective Hypnosis practitioner. She is dedicated to you and your session and will use all her knowledge to help you. You got her complete integrity, professionalism, confidentiality and respect. All sales are final there is none money back guarantee. You can cancel free of charge up to 7 days before the session. I have received and read this Client Information and Agreement Form and understand what l have read. Ciient Signature*Date* DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged. If you prefer to fill it in on paper, print the pdf here and take it with you on the day of your session.