Treatment agreement — Hafiedha Redpath, Integrated Healing

Thank you in advance for taking the time to review and complete the appropriate treatment consent form below. Please submit at least 3 days prior to our session.

Please take a moment to carefully read this information. If you have a medical condition please check with your health care professional before attending your appointment.

For Shiatsu and Therapeutic Massage Clients;

Name

First Name

Last Name

Email

Liability: I, (The Client), hereby release and indemnify, Hafiedha Redpath (The Therapist), 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. By typing my full name below, I agree to these terms and conditions. I agree to indemnify and hold harmless Hafidha Redpath from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including legal costs and fees brought as a result of my involvement in the therapy. Scope of Practice: I understand that Hafidha Redpath is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnosis should not be considered a replacement for the advice and/or services, of a psychiatrist, psychologist, or doctor. I understand the nature of the sessions to be provided. I understand that Hafiedha is not a licensed physician, and that it is my responsibility to maintain a relationship with my medical doctor if I so desire. If I am under medical care for ANY condition, I WILL NOT make any adjustments to any prescribed medication without the approval of my doctor. If I am in any doubt, I will contact my doctor/physician immediately.

By signing this form and ticking the boxes below, I agree to the following;

If at any point during the treatment I am uncomfortable or uneasy with the procedures being administered and/or I experience pain, I understand it is my responsibility to IMMEDIATELY inform the therapist, so that the treatment can be terminated or strokes and pressure can be adjusted to a level of comfort.

Confidentiality; everything discussed remains confidential except where you or another person may be at risk of serious harm.

Privacy will be assured, as I have the right to undress only to my comfort level and according to the requirements of the treatment.

Draping will be used by the therapist as required to expose only those parts of my body that require treatment and/or as I choose to ensure my comfort during treatment.

If at any time during the treatment, I feel uncomfortable with the treatment for any reason, I have the right to request an immediate stop to the session or request modifications to the treatment, regardless of prior consent given.

The therapist may refuse to treat any client or part of their body with just and reasonable cause.

I confirm the details recorded on my pre appointment questionnaire and during this consultation are correct. I have disclosed relevant information. If I have any medical concerns, I understand that I must consult a doctor (and/or midwife). The therapist has explained the treatment for which I give my consent.

I have read and understood the information above and consent to the treatment for the condition discussed with my therapist today.

Date

MM

DD

YYYY

By ticking the above boxes and leaving my name below I confirm that I have read and agree to the Terms & Conditions contained on this page and as are required by Hafiedha Redpath, Integrated Healing

For RTT Hypnotherapy clients

Name

First Name

Last Name

Email

By signing this form and ticking the boxes below I agree to the following

Liability: I, (The Client), hereby release and indemnify, Hafiedha Redpath (The Therapist), 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. By typing my full name below, I agree to these terms and conditions. I agree to indemnify and hold harmless Hafidha Redpath from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including legal costs and fees brought as a result of my involvement in the therapy. Scope of Practice: I understand that Hafidha Redpath is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnosis should not be considered a replacement for the advice and/or services, of a psychiatrist, psychologist, or doctor. I understand the nature of the sessions to be provided. I understand that Hafiedha is not a licensed physician, and that it is my responsibility to maintain a relationship with my medical doctor if I so desire. If I use RTT and am under medical care for ANY condition, I WILL NOT make any adjustments to any prescribed medication without the approval of my doctor. If I am in any doubt, I will contact my doctor/physician immediately. I understand that if I am epileptic or suffer from a psychotic illness it is not recommended that I undergo hypnotherapy. I hereby agree that by signing this form that I do not currently suffer from these disorders. Audio Radio Recording(s): I indicate that I agree to give Hafiedha Redpath full permission to make an audio recording that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s) Hafiedha Redpath retains full copyright over any forms of media that may be produced and distributed to me. I understand that having a recording made of part of my session and my willingness to listen to the recording for 21 days will contribute to my success.

I confirm that I agree to;

I agree to allowing Hafidha Park permission to make an audio recording to be used in my treatment

Participation: I indicate that I agree to give Hafidha Park full permission to hypnotize me and to use Rapid Transformation Therapy knowing that by participating fully in the process and by listening to my personalized recording for 21 days, I play an important role in my overall success. I agree to listen to the personalized recording for full 21 days I agree to being hypnotized by Hafidha Park using Rapid Transformational Therapy I agree to participate fully in the session

Deepening Process: I hereby grant permission to Hafidha Park to guide and direct me, during my Rapid Transformational Therapy session (s) by telling me to raise and drop my arms on my laps, rock my head, in order to help facilitate the deepening process.

Guarantee: I understand that although Rapid Transformational Therapy has an incredibly high success rate, Hafidha Park cannot and does not guarantee results since my own personal success depends on many factors that Hafidha Park has no control over, including my willingness and desire to affect the changes inside of myself.

Confidentiality: By signing this form, I consent that Hafidha Park 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, in imminent danger to myself or others; or if a subpoena of records has been requested. I also understand that, at any time, Hafidha Park may discuss aspects of my case with other colleagues keeping my name and identity completely confidential always unless I have given permission otherwise.