Liability

 

I, (client) , hereby release Victoria Grimsley 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. This liability waiver is not intended to exclude or restrict liability for death or personal injury caused by negligence.

 

Scope of Practice

 

I understand that Victoria Grimsley is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnotherapy should not be considered a replacement for the advice and/or services of a psychiatrist, psychologist, psychotherapist, or doctor.

 

Participation

 

I give Victoria Grimsley full permission to hypnotize me and to use Rapid Transformational Therapy® knowing that by participating fully in the process and by listening to my personalized recording for 30 days, I play an important role in my overall success.

 

Guarantee

 

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

 

Audio Recording(s)

 

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

 

Deepening Process

 

I hereby grant permission to Victoria Grimsley to respectfully lift my arm, touch my shoulder, or rock my head during my Rapid Transformational Therapy® session(s) in order to help facilitate the deepening process.

 

Confidentiality

 

By signing this form, I consent that Victoria Grimsley may release information to a specific individual or agency if it has been determined that a vulnerable person (child or adult) is at risk; 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, Victoria Grimsley may discuss aspects of my case with other colleagues, keeping my full name and identity completely confidential always unless I have given permission otherwise. Full Name: Signature: Date: