I confirm that I give “Infinite Minds” informed consent to receive therapy provided by Julie Teshome or Simon Teshome.
I understand that results may vary from person to person and I am in full agreement for “Infinite Minds” to work on the issues or problems presented by myself.
Julie & Simon Teshome are committed to work with you, using whatever model or techniques that they consider appropriate to your individual situation. This in no way
implies or guarantees a “cure” of the said issues or problems.
Hypnotherapy, or any other therapy provided by Infinite Minds is not a replacement for medical treatment, psychological or psychiatric services or appropriate
counselling.
I understand that Julie & Simon Teshome do not treat, prescribe, or diagnose any condition.
I understand I may need to obtain medical approval from my treating physician to obtain a referral or discuss my treatment with my General Practitioner.
I have been advised that I am free to terminate any or all sessions at any time.
If you are unable to attend or wish to cancel your appointment, at least 24 hours’ notice is expected or a cancellation fee of $50 will be required.
By booking your appointment with “Infinite Minds” you are confirming your agreement to pay these fees under these circumstances.
As members of the Australian Hypnotherapists Association (AHA), Julie & Simon Teshome adhere to the AHA Code of Practice and Ethical Guidelines.
No information obtained during your Session will be available to any third party without your written consent.
If the Therapist has concerns or believes that because of your behaviour, you may harm yourself or another person, it may be necessary to report the situation to
relevant authorities.
This may include situations that are:
1. threats to harm yourself or to another person
2. concerns a child or protected adult is at risk of harm or abuse
3. if you inform or disclose information about a proposed illegal Act.
4. Or if the Australian Courts subpoena Infinite Minds to provide relevant information
To ensure Clients receive effective therapy, both Julie & Simon Teshome undertake ongoing professional development and consult with a Clinical Supervisor. Any
information and material discussed in those contexts are also bound by privacy and confidentiality ethics.
When Clients are referred to “Infinite Minds” by a Doctor or another professional it may be necessary to communicate with the relevant party. This will be handed
on a case by case situation, following discussion with the Client.
Please arrange 10 minutes prior to commencement time of your appointment.
I agree that any mp3 or CD recording provided to you is for my personal use only and not to be lent to, copied, given or sold to any other person.
I agree to participate in each session to the best of my ability, and that contact between sessions will be limited to either telephone or email.
Julie & Simon Teshome provide a service that is respectful of the diversity and individuality of all clients. You will always be treated with kindness and respect. It is expected that all clients will reciprocate this respect.
It is expected that you will not attend your appointment under the influence of alcohol or any substance.
If you are unable to attend or wish to cancel your appointment, at least 24 hours’ notice is expected or a cancellation fee of $50 will be required.
By booking your appointment with “Infinite Minds” you are confirming your agreement to pay these fees under these circumstances.
I have accurately and truthfully answered the questions on this Consent Form and provided the background information as requested by Infinite Minds.
