by Jessica Melendez, CCHt, PMP
Client Participation Agreement
As I enter into this relationship, I agree to the following:
I am participating in hypnosis by my own choice. I understand I am always in control, fully aware, and will have complete recall of my experience during the session. If I happen to fall asleep, I understand I will be quickly, gently re-awakened by a gentle touch to my forehead.
I understand that I am not a “patient,” but a co-operator in my hypnosis experience. I understand when I leave the premises, I will be given techniques and recordings for my private use which are extremely important to my individual success.
I agree to take personal responsibility for my own perceptions, conclusions, and reactions.
I understand that my progress profoundly involves my personal values—i.e., how I care for myself --physically, mentally, emotionally, and--if applicable to my belief system--spiritually.
I understand that transformation is a personal process, and requires my dedicated commitment in and away from sessions. I understand I will be given resources for my private use that can greatly support a successful result. Ultimately, I am fully responsible for the direction of my own free will-- in all my affairs.
As your hypnotherapist, I commit to you to utilize all of my skills to help you to reach your goals in the shortest time possible. You have my assurance of my full integrity, professionalism, confidentiality, and respect!
Contact Information: My name is Jessica Melendez and I can be reached by phone at (352) 604-3451 or by email at [email protected].
Notice: THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY: I am neither a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to a coordinated transfer to another practitioner. A client has a right to refuse hypnosis services at any time. A client has a right to know the expected duration of sessions and may assert any right without retaliation.
Hypnosis Law: I, Jessica Melendez, only practice non-therapeutic hypnosis, i.e., for non-illness/non-diagnosed related issues. However: if you wish to work with me using therapeutic hypnosis for a medical, diagnosed mental health condition, or dental condition-- this requires a written referral from a qualified licensed practitioner.
Certification: I am a member of the International Association of Interpersonal Hypnotherapists (IAIH) and have been certified by the Institute of Interpersonal Hypnotherapy which must be annually licensed with adherence to all applicable federal, state, county, and city regulations. IAIH certified schools are required to provide a minimum of 500 hours of state licensed training, of which I am certified. IAIH adheres to strict guidelines to ensure the attainment of core competencies and educational objectives. I will always operate within the scope of my credentials and within all federal, state, and local laws.
Ethics: I abide by the Code of Ethics of the International Association of Interpersonal Hypnotherapists (IAIH). For more information on the IAIH and its standards for the practice of ethical and professional Hypnotherapy, please visit https://InterpersonalHypnotherapy.com.
Other Services: Services other than my own may be available to you in the community. You may locate such providers through an internet search or by reaching out to the IAIH. As my client you have the right to refuse any aspect of hypnotherapy services or to completely terminate services at any time, or to choose another practitioner.
Fees: The charges for my services are based on a sliding scale. Sessions may run from one to three hours. Unless other arrangements are made, fees are due at the time of each session in the form of cash, check, or credit card. Sessions paid in advance are non-refundable. You will be given a 14-day notice of any change in fees. I do have a 24-hour cancellation policy—please do respect my time and schedule.
Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you. As my client you have the right to complete and current information concerning any aspect of the professional/client relationship.
Insurance: I suggest you think of my services as something that you will pay for personally. That will both protect your privacy and help you value the work you are doing more.
My Approach: It is my goal to help you to achieve lasting results through the use of hypnosis, NLP, meditation, and other related self-help modalities. Through the power—and conscious choice--of your own mind, I will assist you in reaching your goals in a way that you and I both agree to be in your best interest and in a way that is in compliance with state and federal laws, as well as with the standards of the regulating organizations to which I belong. I agree to use my experience to facilitate the changes as are mutually agreed to be in your best interest. I am professionally committed to mobilizing your inner resources in the shortest time possible.
By signing this agreement, you agree with the following declaration:
I am of legal age and in consideration of my acceptance as a participant in this seminar, hypnosis session, regression, training, or any other experience facilitated by ESCANVI Services. I for myself, my heirs, executors, administrators, and assignees, do hereby release and discharge ESCANVI Services and any employees or other participants from all claims of damages, copyright, demands, or actions whatsoever in any manner arising from or growing out of my participation. I understand that recordings (for home use hypnosis) may be made with the permission of the client and ESCANVI Services retains the copyright of these recordings.
Thank you, I look forward to meeting with you!
Jessica Melendez
(352) 604-3451
ESCANVI Services
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Groveland, Florida
(352) 604-3451
Open: 9am - 5pm ET
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Disclaimer: We understand that every individual's experience is unique and results may vary depending on various factors, such as attitude, adaptability, personal history, and overall health. For your safety and well-being, we highly recommend consulting your physician before beginning any program. At ESCANVI Services, we do not diagnose, treat, or prescribe any medical or psychological disorders. We urge you to seek the care of a qualified physician or psychotherapist if you suffer from any psychological or medical disorder. Thank you for choosing ESCANVI Services as your partner in your journey towards wellness.