The Hypno Haven
Agreements
To ensure your sessions are comfortable and productive, please find below the Hypno Haven Agreements, including informed consent, release of liability, disclaimers, and confidentiality.
You will be sent a copy to sign prior to our first session.
Please do not hesitate to contact me if you have any questions.
SESSION AGREEMENTS
I agree to enter hypnotherapy with Birka Burnison., CMS-CHt, FIBH.
I have read and understand the limits of confidentiality, code of ethics, and conditions of our work together.
QUALIFICATIONS AND TRAINING
Birka Burnison (“Birka”) agrees to give undivided attention during sessions and provide professional services in Hypnotherapy and Self-Hypnosis Training in accordance with acquired training and experience.
Education and training in Hypnotherapy is classified under Human Services in the Health and Human Services Division of the Classification of Instructional Programs by the United States Department of Education.
Birka received over 500 hours of hypnotherapy training at the Hypnotherapy Academy of America as a Certified Medical Support Clinical Hypnotherapist (CMS-CHt), a Certified Hypnotherapist in Natal, Interlife and Past Life Regression, and a practitioner of Integral Hypnotherapy™. Birka is a Fellow of the International Board of Hypnotherapy (FIBH).
Birka’s International Board of Hypnotherapy Certification Number: F10823-800.
DESCRIPTION OF SERVICES AND DISCLAIMER
Hypnotherapy services are not licensed by the State of California. These services are complementary to the healing arts services that are licensed by the state.
Hypnotherapy is an educational and self-improvement process that facilitates access to a person’s internal resources to assist him/her/them in solving problems, increasing motivation, or altering behavior patterns to create positive change.
Hypnotherapy work is Client-centered and services, including self-hypnosis techniques, relaxation inductions, affirmations, and guided imagery, etc., are explained to and approved by Client prior to use. It is Client’s right to refuse any aspect of Birka services and to seek the service of another provider at any time.
While hypnosis may be helpful for many purposes, effectiveness may vary and no specific results can be promised or guaranteed. Client is solely responsible for any action that Client takes or refrains from taking in connection with the topics discussed during sessions with Birka.
Hypnotherapy is not a replacement for medical or mental health treatment. No service or product offered is intended for the diagnosis or treatment of any disease, illness, or mental health condition. Birka is not a licensed physician, therapist, social worker, or counselor (etc.), and is not qualified to provide legal, financial, or medical advice.
“Medical support hypnotherapy” is used only as an adjunct to conventional medical treatment. Consultation with a licensed physician is required before medical support hypnotherapy services are provided. Client is advised to seek a Doctor’s approval before making any medical/health/lifestyle changes. Client is to inform Birka of all physical or mental conditions that might affect her work with Client.
This disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code (included below under “California Senate Bill 577 Disclosure”).
CONFIDENTIALITY
Birka is committed to protecting Client’s privacy and preserving Client’s trust. In compliance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations, Birka respects Client’s privacy and holds in confidence information acquired during the professional service.
Client authorizes Birka to communicate information such as appointment reminders, MP3 recordings of sessions (recorded only per Client’s written request, specifying date of session), and other information pertaining to Client’s hypnotherapy sessions only via the following specified and initialed communications:
Email
Phone (*including voicemails & texts)
Phone (*answered calls only)
Whats App (*including voicemails & texts)
Zoom Video Conferencing
Information obtained from Client is never shared with any other persons, verbally, digitally or in hardcopy form, except in the following situations:
a) Client has authorized Birka to share specified information to the designated provider/person(s) and Client has signed a Release of Information form.
b) Information is required by a Court mandate.
c) Any suspected child abuse, dependent adult abuse, or elder abuse.
d) Client is threatening serious bodily harm to another person(s).
e) Client discloses to Birka their intent to harm themselves.
PAYMENT
Payment is required at the time of service. Birka does not accept insurance, but will send Client an invoice that Client may submit to insurance. Payment is accepted by cash, check, Venmo, or PayPal.
SCHEDULING AND CANCELLATIONS
Client will receive scheduling and cancellation confirmations within 24 hours.
First cancellation or missed appointment is excused and may occur up to scheduled appointment. Subsequent cancellations must occur at least 24 hours before scheduled appointment or Client will be charged a $50 fee. Missed (not canceled) appointments will be charged in full.
REFUNDS AND COMPLAINTS
Refund policy is based on Client’s satisfaction with their hypnotherapy experience. If Client expresses dissatisfaction with their hypnotherapy sessions, a refund will be offered. If the client chooses to accept a refund, it will be immediately provided.
If Client purchased a discounted session package, unused sessions will be refunded or credited to Client’s account.
If Client should have a complaint about the facilitation process that has not been satisfactorily resolved by Birka , please feel free to contact:
The International Board of Hypnotherapy at 2132 Osuna Rd. NE, Suite B, Albuquerque, NM 87113.
CONSENT AND RELEASE OF LIABILITY:
In consideration of my acceptance as a client of Birka Burnison and participating in hypnotherapy sessions with all described methods and tools herein, and any others deemed useful within Birka’s scope of expertise, I (Client’s name) of legal age, for myself, my heirs, my executors, administrators and assignees, do hereby waive, release and discharge any and all claims for damages arising from, or growing out of my participation in said activities, including personal injury, or property damage or losses, expenses, or reasonable attorney fees, which I may have or which may hereafter accrue to me, against Birka Burnison.
California Senate Bill 577 Disclosure
California Law allows access by California residents to complementary practitioners who are not providing services that require medical training and credentials. The following disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code.
California does not have an explicit statute or regulation requiring licensure for hypnotists or hypnotherapy. California Business and Professions Code 2908 exempts “persons using hypnotic techniques” from the psychology licensing act to do “vocational or avocational self-improvement” as long as they “do not treat emotional or mental disorders.” 2908 also exempts “persons using hypnotic techniques” they are working under referral “of persons licensed to practice psychology, dentistry or medicine.”
California Business and Professions Code 2053 requires that complimentary health care providers make certain written disclosures to clients. If hypnotherapists are deemed to be covered by this provision, they must make the required disclosures:
1) A person who provides services pursuant to Section 2053.5 that are not unlawful under Section 2051 or 2052 shall, prior to providing those services, do the following:
a. Disclose to the client in a written statement using plain language the following information:
i. That he or she is not a licensed physician.
ii. That the treatment is complementary to healing arts services licensed by the state.
iii. That the services to be provided are not licensed by the state.
iv. The nature of the services to be provided.
v. The theory of treatment upon which the services are based.
vi. His or her educational, training, experience, and other qualifications regarding the services to be provided.
b. Obtain a written acknowledgment from the client stating that he or she has been provided with the information described in paragraph (1). The client shall be provided with a copy of the written acknowledgment, which shall be maintained by the person providing the service for three years.
2) The information required by subdivision (a) shall be provided in a language that the client understands.