Before you come in for a visit, check this out!

Please slowly read the following explanation of services in this disclosure.  You will notice the highlighted areas to be able to answer 3 questions at the end of the disclaimer and explanation of the hypnosis "treatment".  Then you will see a brief biography.  You will consolidate time in the office by pre-reading on this in advance.

DISCLOSURE OF SERVICES

The purpose of a program of hypnotherapy is for vocational and avocational self-improvement (Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state.  A hypnotherapist is not a licensed physician or psychologist and Jaine Benson is not licensed and does not prescribe nor diagnose.  Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures.  Any information shared is for educational purposes only.
Hypnosis works with the power of the subconscious mind to change habits and behaviors.  The subconscious mind is considered to be the source or root of many of our behaviors, emotions, attitudes and motivations.
IT IS NOT POSSIBLE TO DETERMINE HOW MANY SESSIONS IT TAKES TO RESET THE SUBCONSCIOUS MIND.  While hypnosis may be an effective technique for many purposes, the effectiveness may vary from individual to individual, and no specific results or progress can be promised or guaranteed.  Even a past life therapy session may not produce your mind’s desire, while the subconscious blocks things for a reason, and we are not to remove defense blocks.
During hypnotherapy sessions, clients remain completely aware of everything that is going on.  In fact, many people experience a hyper-awareness where sensations are perceived enriched and vivid.  The ability to visualize or imagine is enhanced.  Deep relaxation is common.  Many describe the hypnotic state as a complete and total escape from physical tension and emotional stress, while remaining completely alert.
The use of hypnosis could elicit memories of past events which may or may not be literally true.  It is possible that events under hypnosis will be distorted or misconstrued.  Without corroborating information, it is not possible to determine whether a specific memory is true or false, even if it seems true to the client.  While it is the practice of Hypnotherapists to keep information confidential, information revealed in hypnotherapy is not subject to the psychotherapist-patient privilege.  A court may order disclosure of information learned in therapy.   ALSO, you must not have hypnosis for a court case, as it will not stand.
I understand that confidential applies to everything said in the session except if I would intend to hurt myself or others, at which time, Janie Benson is obligated to call for referrals on my behalf.  Also, If I have a condition outside the scope of hypnotherapy self improvement, I may be required to provide a referral from a licensed professional.  .   I may be asked to engage in a 12 step program, with verified reports in order to continue with this type of therapy. 
I understand that if I come to the session with alcohol in my system I will probably throw up, and that this therapist is not 420 friendly, which means that altered states are not for this venue, and will be referred out.
I have received a copy of this disclosure and understand the information described above. I have also read on the other side of this document a biography of the Hypnotherapists education, training, experience and other qualifications regarding the services to be provided.

Client Name (please print):  ________________________________________________

Client Signature:  _____________________________________ Date:  ___________________ 

Now that I have read the disclosure, I can answer these T/F questions easily.
1) I might hear about physical symptoms that create a mind body response I understand that it is not a diagnosis and is only used for education,    T
2) I am able to visualize, picture pretend or imagine with enhanced vivid ability.  T
3) I expect instant reults no matter what the reason I am coming to get help.  F

BIOGRAPHY 

                                               JANEY BENSON  HYPNOTHERAPIST


Education:
Graduated from the Hypnosis Motivation Institute, Tarzana California, November 2009
Completed a one year course of instruction in hypnosis from the nation’s only accredited college of hypnotherapy including an internship of practical experience under the supervision of staff instructors holding teaching credentials from the State Department of Education.

Have conducted a private practice since 2009 assisting clients in achieving their personal goals in such areas as habit modification, stress reduction, overcoming fears and performance anxiety, increasing self-confidence and self-esteem. 
Continuing Education:
Grieving for Professionals, 6 CEUs, Feb 2012

HUNA energy practitioner
PLR, Past Life Therapy Certification
Certified Angel and Emissary Imagery Facilitator, American Hypnosis Institute.
Dolores Cannon Method training, February 2011
Pre and Post surgery certification, August 2011
Seminars:
I have led workshops for:
Hospice volunteers on guided imagery for compassion fatigue
Teachers
Students with learning stress
Iowans in Workforce Development
Peace for Today Radio Listeners
Arctic Inuit FASD project.
Personology and muscle testing facilitator
Feuerstein Instruments of cognitive mediation
Non relevant  Studies in French, Augsburg College, Universite Laval, University Catholique de l’Ouest, Alliance Francaise, Lycee Albert Calmette, Conservatoire de la musique, Nice.