Notice: THE STATE OF MISSOURI HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY. Hypnotism is a self-regulating profession and its practitioners are not licensed by state governments. The services provided by Alliance Coaching Institute are held out to the public as non-therapeutic hypnotism. Alliance Coaching Institute does not represent its services as any form of health care or psychotherapy, and makes no health benefit claims for these services, neither stated nor implied.
I realize that M. K. Hilterbrand is a Certified Consulting Hypnotist trained in hypnotism and is a member of the National Guild of Hypnotists, who practices in accordance with it’s Code of Ethics and Standards, and does annual continuing education to maintain his training at a high level.
I also understand that M. K. Hilterbrand is an educator and unconscious coach, not a medical doctor or psychologist, and that he cannot diagnose disease, prescribe, or treat medical conditions or serious disorders. I understand that the coaching and training I am receiving from Alliance Coaching Institute is not a substitute for normal medical care and I have been advised to discuss this procedure with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and/or medications and consult my regular physician for treatment of any new or old illnesses. The tools of self-discovery and awareness learned are to be viewed as a compliment to any medical treatment prescribed by a physician. I am willing to be guided through various methods, including relaxation, breath work, visual imagery, creative visualization, positive affirmation, hypnosis, Neurolinguistic Programming (NLP), Emotional Freedom Techniques (EFT), and stress reduction processes for the purposes of vocational or avocational self-improvement, the learning of self-hypnosis to induce positive thinking, create commitment to change and to learn the techniques to produce self-control over physical experiences and emotional awareness, and understand that self-awareness development and other techniques may produce physical and emotional responses.
I realize that although M. K. Hilterbrand has considerable training and experience, the training and insights he provides, are not a cure, and I accept that I am paying for his time, expertise, and insights, irrespective of any particular result.
I agree to pay the program fee to Alliance Coaching Institute and understand that fewer sessions may be required to resolve my issues and/or challenges to my complete satisfaction in the sole discretion of Alliance Coaching Institute. I understand that if this is the case, then I am not entitled to receive all remaining sessions, nor am I entitled to any refund, in whole or in part. I also understand that no hypnosis will be performed during my first session.
I understand that all the entire program fees are to be paid in full in advance before scheduling my first appointment unless other arrangements have been previously made.
I understand that all program fees are non-refundable.
I understand that Alliance Coaching Institute does not accept third party billing or forms of payment, and suggests that I think of the services provided as something that I will pay for personally. I have been informed not to expect any reimbursement from an insurance company.
I recognize that it is impossible for anyone to guarantee human behavior. Success is dependent on many variables, including my attitude, motivation, and cooperation, as well as my attending of scheduled sessions.
As people vary, so may the time duration needed for each individual to achieve his or her individual goal. Therefore, after the program is completed, Alliance Coaching Institute will be available to provide reinforcement sessions at the client’s request, as needed, at the regular hourly rates, until the client is satisfied and has attained his or her desired results.
I understand that in order to qualify for any stated guarantee, I must complete my program in which I have enrolled which includes, but is not limited to: completing all sessions, keeping all session appointments, arriving to all session appointments on time, completing all assignments in between sessions, and providing a letter from my attending Primary Care Physician stating the date of the visit to my doctor’s office when I received permission to begin practicing hypnosis.
I understand that good and lasting results may require several sessions, and that I may be required to practice self-hypnosis and/or listen to reinforcement recordings between sessions at home. I am responsible for actively cooperating with, and participating in, my program. Alliance Coaching Institute shall not be held accountable for the results I attain. I understand that my program may be terminated if deemed appropriate and that I may be referred elsewhere for proper treatment.
I understand that I am responsible for my own health and well being, and I agree to indemnify and hold harmless M. K. Hilterbrand and Alliance Coaching Institute for any and all negative experiences.
If any medical symptoms progress or become acute I agree to seek medical attention from a licensed healthcare provider immediately. In the event of a medical emergency or if I feel suicidal, I will call 911 or other emergency help. I agree to inform my hypnotist immediately of any adverse feelings or experiences related to this process, at the time of my awareness of them. I have been informed as to the limits of hypnosis effectiveness and offered referral to other providers of alternative approaches to problem solving.
I have read this agreement and understand that Alliance Coaching Institute will not release any information to anyone without a written authorization from me, except as provided for by law. I have a right to be allowed access to my written record about myself.
I am over age 18, and have been informed and consent to services offered by Alliance Coaching Institute to engage in the process of non-therapeutic hypnosis. I also understand that the process of hypnosis requires physical touch and I consent to being touched physically in an appropriate manner. I understand that I will have all choices at all times and can start and end the process at anytime, even during my session. I have a right to be free of physical, verbal or sexual abuse. I have a right to know the expected duration of sessions, and may assert any right in a calm, reasonable manner without fear of retaliation. I also agree that either Alliance Coaching Institute or myself may terminate this relationship at any time for any reason whatever.