Client Registration

Client Information

First Name *

Last Name *

Email *

Phone *

Date of birth *

Address *

Province/State *

Country *

Postal code/Zip *

Gender *

Female

Male

Prefer not to Disclose

Occupation *

What is your relationship status? *

Children? *

Emergency Contact *

What are your preferences with regard to our communications between sessions? *

Text Message

Phone Call

Email

Would you like to be added to the newsletter? *

Yes

No

Name of person who referred you? (We offer special discounts on future services as a thank-you when you refer someone who attends a paid session!) *

What is your preferred approach to sessions? *

In Person

Google Meet

Medical History

Have you ever had hypnotherapy before? *

Yes

No

Stage/Entertainment Hypnosis

1. What is your intention for booking? What would you like to get out of the session(s)? *

2. How would you describe your overall health? *

3. Have you ever been diagnosed with a medical or psychiatric condition? *

4. Are you taking any medications or supplements? *

5. Are you presently undergoing any Medical, Psychological, or Alternative treatment? *

6. Do you have any allergies? *

7. Have you ever self medicated over a prolonged period with alcohol, recreational drugs or otherwise? *

8. Is there anything important that you need to disclose to the practitioner? *

Consent to Treatment

Client Agreements (Must Check All) *

I understand that the success of my sessions at Serenity Healing Sanctuary Inc. greatly depends on my own desire for change and active participation. I acknowledge that there is no guarantee of specific outcomes from my sessions.

I commit to actively participating in each session to the best of my ability. I understand that it is my responsibility to communicate openly with my practitioner to maximize the benefits of my sessions.

I understand that I am solely responsible for my own choices and actions. I acknowledge that all education and resources provided are for informational purposes only and are to be used at my own risk.

I acknowledge that the services provided by Serenity Healing Sanctuary Inc. are complementary to conventional medical treatment and are not intended to replace medical advice from a licensed healthcare provider.

Confidentiality *

I understand that my session may be audio/video recorded for continuity of care. All session notes and recordings will be kept confidential. Personal information will be used solely for the purposes of providing services and will not be shared without explicit consent, except as required by law or mandatory reporting.

Technology *

I understand that online services carry the risk of unauthorized access to personal information. Serenity Healing Sanctuary Inc. and its practitioners will make every reasonable effort to ensure the security of personal information.

Light Touch - My therapist facilitates treatment that may include light touch. I acknowledge that the light touch techniques used are gentle and non-invasive. All touch will be conducted in a respectful and professional manner, ensuring client comfort and safety at all times. I understand that I have the right to withdraw consent for light touch at any time. I understand that I will remain fully clothed throughout the entire session. I agree to communicate openly with my practitioner about any discomfort or boundaries. *

I CONSENT to light touch

I do NOT CONSENT to light touch

Termination of Services *

Serenity Healing Sanctuary Inc. reserves the right to terminate services if the client fails to adhere to the terms of this agreement or engages in behavior that disrupts the therapeutic process. I acknowledge that I also have the right to refuse or discontinue services at any time.

Payments, Cancellations and Refunds (Must Check All) *

Payment can be made upon booking via online payment or email money transfer prior to your session. Prepaid fees are to be used within one year of payment.

Missed appointments or cancellations made with less than 48 hours notice will result in a full charge of services or a deduction of one session from a package. Exceptions may be made at the discretion of the practitioner. It is my responsibility to communicate with the practitioner if an emergency arises.

All fees are non-refundable and non-transferable. Credit may be granted at the discretion of the owner but is not guaranteed. Refund requests must be submitted in writing. Any credit granted will have a one-year expiry date.

Serenity Healing Sanctuary Inc does not offer direct billing. It is my responsibility to check with my insurance company regarding any benefits offered for my sessions and to submit my own invoices to my insurance company as required. Payment in full is required regardless of insurance coverage.

Waiver of Liability for Serenity Healing Sanctuary Inc. *

By signing below, I agree to hold harmless and release Serenity Healing Sanctuary Inc., its directors, officers, practitioners, employees, agents, affiliates and representatives from any and all, direct or indirect, actions, claims, losses, demands, expenses, liabilities or damages of any nature without exception.

I understand and acknowledge that my participation in any session, activity or service with Serenity Healing Sanctuary Inc. is completely voluntary. I confirm that the information I have provided is accurate and complete to the best of my knowledge. I agree to inform my practitioner of any changes in my health status that may affect my sessions. By singing below and submitting this information, I confirm that I have fully read, understand, and agree to all the terms and conditions outlined above. *

Date Signed

Signature *

Clear

[email protected]

(403) 630-1186

Calgary, Alberta

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