Austin Hypnotherapy Solutions

Child Intake Form

Child Intake Form


Client Information–Children

Note: If the reason for today’s visit has to do with a medical issue, it will be necessary to obtain your physician’s approval to use hypnotherapy as an adjunct to medical treatment.

Client Consent Form

Fees: Our service fees are $125.00 per session for children under the age of 18. Sessions will last 45 minutes to an hour. Payment is due in full at the time of the session. Visa, MasterCard, Discover, Venmo, cash or check are all acceptable forms of payment. Cash and check are always appreciated.

Cancellation Policy: Your appointment time is reserved exclusively for you. Please arrive promptly to obtain your full session. If you must cancel or reschedule, we require 48-hour notice. Unless cancelled prior to 48 hours, you are financially responsible for 50% of the scheduled fee. If you cancel within 24 hours, you are financially responsible for 100% of the scheduled fee. If you must cancel or reschedule due to an emergency, please notify us as soon as possible.

Confidentiality: All hypnosis sessions are confidential. We will not release any information to anyone without written authorization from you, except as provided by law.

Notice: Hypnosis is a natural and safe, self-help process. Hypnosis is not the practice of medicine or psychotherapy. The hypnosis and coaching services provided are for educational and self improvement purposes and are not intended for the diagnosis or treatment of any medical or psychological condition. If you have an ongoing medical illness, mental disability, or mental illness, please consult a medical doctor, psychiatrist or psychologist licensed by the State of Texas. We do not represent our services as any form of health care and despite research to the contrary, by law we may make no health benefit claims for our services.

Redress: We offer hypnosis services in accordance with the Code of Ethics and Standards prescribed by the American Council of Hypnotist Examiners. If you should have a complaint which we have not resolved to your satisfaction, please feel free to contact the American Council of Hypnotist Examiners at 7183 Navajo Road, Suite E San Diego, Ca 92119. It is your right to refuse any aspect of our services and to seek the services of another hypnotherapist at any time.

Client Consent and Release: I am the legal guardian for the child listed below. In consideration of my child’s acceptance as a participant in hypnosis and coaching sessions, seminars or any other Austin Hypnotherapy Solutions, LLC production, I for myself, my child, my heirs, executors, administrators, and assignees, do hereby release and discharge Austin Hypnotherapy Solutions, LLC and Pam Krewson and any of their employees or other participants from all claims of damages, copyright, demands or actions whatsoever in any manner arising from my participation. Further, I understand that audio recordings
are made during some sessions, and that Austin Hypnotherapy Solutions, LLC, retains the copyright of these recordings.

I declare that I have read this consent and release and that I fully understand and agree to the terms described.

 Client Signature (If under 18, must be signed by legal guardian)  

Sign Here