Presenting Issue Questionnaire

Vickey Bolling, CCHt, MALS

Shift Hypnotherapy, LLC

Regus Sterling Pointe

303 Perimeter Center North, Suite 300, Atlanta, Georgia 30346

Vickey Bolling, CCHt, MALS

Certified Clinical Hypnotherapist

Specialist Practitioner in Neuro-Hypnotic Repatterining

Licensed NLP Practitioner in Neuro-Linguist Programing

Past Life and QHHT Regression Hypnotherapist

Liability

I, (The Client), hereby release Vickey Bolling (Hypnotherapist) from any liability or claims that could be made against her concerning my mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form.

 Scope of Practice

I understand that Vickey Bolling is not a licensed physician, psychologist or psychotherapist and that neither neuro-linguist programing (NLP) past life regression (PLR), quantum healing hypnosis technique (QHHT), advanced conversational hypnosis (ACH), nor pure hypnosis should be considered a replacement for the advice and/or services of a psychiatrist, psychologist, psychotherapist, or doctor. I also understand that neither life regression, QHHT, nor hypnosis is a substitute for any medication.

Participation

I give Vickey Bolling full permission to utilize any of the techniques listed in the scope of practice, knowing that by participating fully in the process and by listening to my personalized recording—if the technique requires—for 18-66 days, as this is scientifically proven to be the time required for the mind to inhabit new behavior. I understand my responsibility and the role I play in my overall success.

Guarantee

I understand that although hypnotherapy, NLP, ACH, PLR, and QHHT therapies have a high success rate, Vickey Bolling cannot and does not guarantee results since my success depends on many factors that Vickey Bolling has no control over, including my willingness and desire to affect the changes inside of myself.

 Audio Recording(s)

I give Vickey Bolling full permission to make audio recordings that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s), Vickey Bolling retains full copyright over any forms of media that may be produced and distributed to me.

 Deepening Process (in-person)

If the technique(s) being used warrant touching of the shoulders, arm, or forehead, I hereby grant permission to Vickey Bolling to respectfully do so in our session(s) in order to help facilitate the deepening process

Confidentiality

By signing this form, I consent that Vickey Bolling may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested. I also understand that, at any time, Vickey Bolling may discuss aspects of my case with other colleagues, keeping my full name and identity completely confidential always, unless I have given permission otherwise

 Cancellation and Refunds

I accept that all appointments be canceled within 48 hours’ notice, or I will be charged in full. I also understand that my investment in these session(s) is non-refundable. A agree to pay the required $100.00 deposit fee when booking my session—which is applied to the total cost of the session. Full payment is due before—or on session date. This fee is refundable if cancellation is done within 48 hours.