Client Bill of Rights and Informed Consent

Contact Information

My name is Dana Reynolds. You can reach me at:

• Email: [email protected]
• Phone or text: 479-256-0211
• Website: https://bespokehypnosis.us

Education and Training

I am a Certified Member of the National Guild of Hypnotists (NGH) and a Certified Member of the International Association of Professional Conversational Hypnotists (IAPCH). My current credentials include:

• Certified Hypnosis Trainer, National Guild of Hypnotists (certified to teach the NGH 100-hour course)
• Consulting Hypnotist (CH), National Guild of Hypnotists
• Certified Ericksonian Hypnotist, International Association of Professional Conversational Hypnotists (IAPCH)
• Grief Recovery Method Advanced Specialist, The Grief Recovery Institute
• Pain Management with Hypnosis PDIS, American School of Clinical Hypnosis
• End of Life Coach, Boulder Institute of Conscious Dying
• NLP Practitioner
• Shamanic Practitioner
• HeartMath Clinical Certification

I received my Consulting Hypnotist certification from the National Guild of Hypnotists through Burt Goldman’s Hypnovision in Palm Desert, California. I was later trained by Don Mottin, Vice President of the National Guild of Hypnotists, in Las Vegas, Nevada, and I receive continuing training from Igor Ledochowski, Master Ericksonian hypnotist with the Hypnosis Training Academy. In 2012, I completed NLP training with Boyd Johnson, NLP Master Instructor and hypnotist.

I take part in continuing education in each of my practice areas to keep my training at a high level.

Notice: AS THE STATE OF ARKANSAS HAS NOT ADOPTED EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM, THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY.

Your Rights as a Client

Hypnotism is a self-regulating profession, and its practitioners are not licensed by state governments. I am not a physician or a licensed health care provider. I cannot provide a medical diagnosis, recommend that you discontinue any medically prescribed treatment, or prescribe drugs.

As my client, you have the right to:

• Seek a diagnosis or any other type of treatment from a different practitioner at any time.
• A coordinated transfer of services to another practitioner if you end my services.
• Refuse hypnotism services at any time.
• Be free of physical, verbal, or sexual abuse.
• Know the expected duration of your sessions.
• Assert any of these rights without retaliation.

Redress

I am a certified member and instructor of the National Guild of Hypnotists, and I practice in accordance with its Code of Ethics and Standards. If you have a complaint about my services or conduct that I cannot resolve with you personally, you may contact the National Guild of Hypnotists to seek redress:

• National Guild of Hypnotists, P.O. Box 308, Merrimack, NH 03054-0308
• Phone: (603) 429-9438

Other providers besides me may be available to you. You can find them through online directories or on the NGH website.

Online Sessions on Zoom

All sessions take place online through Zoom. You book your sessions through the scheduler on my website, and you will receive a Zoom confirmation email with your session link. To help your session go smoothly and safely, please:

• Join from a private, quiet space where you will not be interrupted.
• Never join a session while driving or operating machinery. Hypnosis requires your full, relaxed attention.
• Use a device with a stable internet connection, working camera, and microphone, and have it charged or plugged in.
• Have a phone nearby. If we are disconnected, I will try to reconnect through Zoom or reach you at the phone number you provided.

Please note: Bespoke Hypnosis is not a crisis or emergency service. If you are in crisis or having thoughts of harming yourself or others, call or text 988 (Suicide & Crisis Lifeline). In an emergency, call 911.

Fees, Payment, and Rescheduling

• My services are private pay, and fees are subject to change.
• Sessions are prepaid at the time of booking through my website.
• Payment is made electronically by credit or debit card through secure online checkout (Stripe).
• Fees are nonrefundable.
• You may reschedule free of charge with at least 2 hours’ notice.
• Reschedules with less than 2 hours’ notice, and missed appointments, are charged a $25 fee to reschedule.

To reschedule, use the Reschedule link in your Zoom confirmation email, or call or text me at 479-256-0211.

Insurance

I suggest you think of my services as something you will pay for personally. This protects your privacy and helps you value the work you are doing. In general, insurance companies rarely cover hypnosis services, and I caution you not to expect them to do so.

Confidentiality and Records

I will not release any information about you to anyone without your written authorization, except as provided by law. You have the right to access my written record about you.

Your records, such as intake forms, agreements, session notes, recordings, and transcripts, are stored electronically in secure client management software.

Audio and Video Recording

All sessions are recorded on Zoom and transcribed, for my session notes and for yours. Zoom displays a notice on screen while recording is active. Bespoke Hypnosis retains ownership of the recordings, and they are shared only privately with you. Recordings and transcripts will never be made public.

I retain all session recordings and transcripts as part of my professional records, including for documentation and liability purposes. You may request a copy of your own recordings at any time. By signing this document, you acknowledge and agree that your sessions will be recorded and transcribed and that I will retain them.

Clients Under 18

I welcome clients under 18 with the consent of a parent or legal guardian. Before services begin, a parent or legal guardian must review this document, consent to services, and sign below on the client’s behalf.

My Approach

The services I provide are offered to the public as non-therapeutic hypnotism, defined as the use of hypnosis to instill positive thinking and the capacity for self-hypnosis, together with coaching for personal growth. My services also include NeurOptimal® Neurofeedback and HeartMath®. These services are not represented as any form of health care or psychotherapy. Despite research to the contrary, by law, no health benefit claims are made for the services provided.

Terms and Conditions for All Bespoke Hypnosis Sessions

By signing below, I, the client, agree to the following:

I understand that hypnosis may change how I feel, physically or emotionally, regarding any pre-existing or future medical condition. It is my responsibility to inform any and all medical practitioners who prescribe my treatment that I am pursuing hypnosis, so they may take it into account when diagnosing my reported symptoms and mental and emotional states.

Regarding any changes I may experience due to hypnosis, I will not alter my medical treatment, prescriptions, therapy, or dosages, or in any other way go against the prescribed advice of my physician, without first consulting my physician.

I understand that hypnosis alone cannot change my behavior against my will or cause me to act in opposition to my personal code of ethics. I hereby release Dana Reynolds and her representatives from any liability regarding my future actions. Hypnosis, neurofeedback, and life coaching are not medical treatment. Any course of action I take as a result of these services is under my own power and is my exclusive responsibility.

If I am seeking hypnosis for a diagnosed medical or mental-health condition that is currently under a provider’s care (for example, pain, depression, or an anxiety disorder), I understand that a completed Physician Referral / Consent for Hypnosis form from my physician or other licensed provider is required before sessions for that condition begin. A referral is not needed for general goals such as stress, habits, confidence, or sleep.

I understand that hypnosis is not “magic,” and that it will not override my free will or change my behavior without effort on my part. Instead, as practiced by Dana Reynolds, it is a tool to access and optimize my own inner resources, enabling growth and improvement by shifting and reframing unwanted patterns that no longer serve my life and lifestyle. I commit to doing my part in following the advice, guidance, exercises, and intentions offered for my well-being, and I assume all responsibility for my progress.

Acknowledgment and Signature

I have read and agree to this Client Bill of Rights and Informed Consent, and I have had the opportunity to ask questions about it.

Client name (printed): ______________________________

Client signature: ______________________________

Date: ______________________________

If the client is under 18:

Parent/guardian name (if client is under 18): ______________________________

Parent/guardian signature: ______________________________

Date: ______________________________