Signature Required Prior to Scheduled Appointment

Pieter Elsen, Certified Clinical Hypnotherapist

Acknowledgment of Services and Fees: Subject: Self Improvement Program

I, the undersigned, acknowledge that I understand and agree to the following:

I agree to pay you, Pieter Elsen, Certified Clinical Hypnotherapist, a fee of $125 per 1-hour session. I agree to pay, in full, for your services on the date of the session.

I understand that missing a scheduled appointment without prior cancellation, or with cancellation less than 48 hours before the scheduled session, will be charged to me at the current full rate.

I understand that the program of conditioning offered by you for the fees described above will include one 1-hour session only. I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professional Code 2908). I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of Pieter’s sessions. I claim no refund accordingly or hold Pieter Elsen responsible in any way, including financially, legally, or otherwise. I also agree to allow Pieter Elsen in his capacity as a therapist to touch my arm, shoulder for the purpose of establishing hypnotic anchors required as deepening techniques for my session.

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I also agree to keep confidential the contents of this session, as well as the script used during the session and agree not to share, utilize, distribute, use for personal gain or otherwise the materials and techniques used during the session, being hereby informed the materials/scripts/techniques are copyrighted and protected by Pieter Elsen. I will NOT record the session secretly during the meeting with for example a recorder or on my cell phone.

I hereby certify that I am over the age of eighteen and that I have read, understood, and agreed to the foregoing.

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COVID-19 Liability Release Waiver

Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Pieter Elsen is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance CDC Professional and Occupational Regulation guidance.

Symptoms of COVID-19 include:

  • Fever
  • Fatigue
  • Dry Cough
  • Difficulty Breathing

I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS. I understand that Pieter Elsen cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client. All surfaces will be wiped thoroughly with hospital grade disinfectant before and after each client according to the manufacturer's directions

By signing below, I agree with each statement above and release Pieter Elsen from any and all liability for the unintentional exposure or harm due to COVID-19.

(Signature)