The client hereby releases Kiki Ypsilanti 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 Kiki Ypsilanti, although being a licensed Dental Surgeon-Periodontist ( medical practitioner), she is not a licensed psychiatrist or psychologist and that hypnotherapy should not be considered a replacement for the advice and/or services of a psychiatrist, psychologist, psychotherapist, or a GP doctor.
Participation
I give Kiki Ypsilanti 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 21 days, I play an important role in my overall success.
Guarantee
I understand that although Rapid Transformational Therapy® has an incredibly high success rate, Kiki Ypsilanti cannot and does not guarantee results, since my own personal success depends on many factors that Kiki Ypsilanti has no control over, including my willingness and desire to affect the changes inside myself.
Audio Recording(s)
I give Kiki Ypsilanti 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), Kiki Ypsilanti retains full copyright over any forms of media that may be produced and distributed to me.
Deepening Process
I hereby grant permission to Kiki Ypsilanti 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 Kiki Ypsilanti 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, Kiki Ypsilanti may discuss aspects of my case with other colleagues, keeping my full name and identity completely confidential always unless I have given permission otherwise.
Information /Data of Intake Form
I confirm that all the data and personal/medical information I have provided for the completion of my RTT intake form to Kiki Ypsilanti, are complete, up to date and sincere , without false, absent or misleading reports from my side.
I also confirm that I do not suffer (or have suffered in the past) from any of the conditions /symptoms listed below:
1)Psychosis 2) Schizophrenia 3) Hallucinations (visual/auditory) 4) Personality disorders 5) Dissociative disorders 6) Schizoaffective disorders 7) Epilepsy 8) Bipolar disorder
In case I have/had experience of any of the above conditions, I give full permission to Kiki Ypsilanti to contact my GP doctor/ psychiatrist/ psychologist to obtain more information and I acknowledge that Kiki Ypsilanti has full right to deny offering me her services if necessary, in order to protect and not risk my mental/emotional health.
