Waiver & Presenting
Issue Questionnaire

Waiver & Presenting Issue Questionnaire

Waiver Form Shift Hypnotherapy, LLC
 Vickey Bolling, CCHt, MALS, NLP, MACH

Shift Hypnotherapy, LLC

Regus Sterling Pointe

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

Vickey Bolling, CCHt, MALS

Specialist NLP Practitioner in Neuro-Hypnotic Re-pattering

Licensed NLP Practitioner in Neuro-Linguist Programing

Cognitive Behavior Life Coach Certification (CBT)
      

Health and Wellness Coaching Certification (CPD)


Master Advanced Conversational Hypnotherapy (MACH)

Liability

I, (The Client), hereby release Vickey Bolling, Hypnotherapist, from any liability or claims related to my mental and/or physical well-being during the work outlined and agreed upon through this form, both now and in the future.

 Scope of Practice

I understand that Vickey Bolling is not a licensed physician, psychologist, or psychotherapist. I also understand that neuro-linguistic programming (NLP), Master Advanced Conversational Hypnotherapy (MACH), Cognitive Behavior Life Coaching (CBT), past-life regression (PLR), traditional hypnotherapy, and any other therapeutic approaches offered are not replacements for the advice, diagnosis, treatment, or services of a psychiatrist, psychologist, psychotherapist, physician, or other licensed medical professional. I further understand that hypnosis and related approaches are not substitutes for prescribed medication or medical care.

Participation and Client Responsibility

I give Vickey Bolling permission to use any techniques listed in the Scope of Practice. I understand that meaningful progress depends on my honest, active participation and that this process may create opportunities for cognitive and behavioral change. If personalized recordings are created, I understand that I am responsible for listening consistently each day for the recommended timeframe. I also understand that my overall success depends, in part, on my commitment, participation, and follow-through.

No Guarantee of Results

I understand that, although hypnotherapy, NLP, CCHt, MACH, PLR, and related approaches may be effective for many clients, Vickey Bolling cannot and does not guarantee specific results. I acknowledge that outcomes depend on many factors outside her control, including my willingness, desire, and readiness to make changes within myself.

While Vickey Bolling cannot offer a guarantee of a therapeutic outcome, to date— she has helped at least 95 percent of her clients achieve their desired outcome.

In-Person Deepening Process

If the technique being used involves light, respectful touch to the shoulders, arm, or forehead, I give Vickey Bolling permission to do so during session(s) when appropriate 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 agree to pay the required session fee in full before my session. I understand that session payments are non-refundable except as described in this cancellation policy. Appointments must be canceled at least 48 hours in advance to receive a full refund. If cancellation occurs with less than 48 hours’ notice, a $100 cancellation fee will be charged, and the remaining balance of the initial payment will be refunded. If multiple sessions apply, you have 9 months from the initial session to complete the rest, unless otherwise arranged.