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Last Name

LIABILITY I, (The Client Filling Out This Form), hereby release Emily Rose Summersett (The hypnotist) 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. SCOPE OF PRACTICE I understand that ​Emily Rose Summersett is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnosis should not be considered a replacement for the advice and/or services, of a psychiatrist, psychologist, psychotherapist, or doctor. PARTICIPATION I give Emily Rose Summersett ​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, Emily Rose Summersett ​cannot and does not guarantee results since my own personal success depends on many factors that Emily Rose Summersett has no ​control over, including my willingness and desire to affect the changes inside of myself. AUDIO RECORDING(S) I give Emily Rose Summersett ​full permission to make audio recordings that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s) Emily Rose Summersett​ ​retains full copyright over any forms of media that may be produced and distributed to me. DEEPENING PROCESS (LIVE SESSIONS) I hereby grant permission to Emily Rose Summersett ​to respectfully lift my arm, touch my shoulder, or rock my head during my Rapid Transformational session(s) in order to help facilitate the deepening process. CONFIDENTIALITY By checking the box below, I consent that Emily Rose Summersett ​may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; 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, Emily Rose Summersett ​may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise. I have read and agree to the terms above. By checking this box it also serves as my signature.

I HAVE READ AND AGREE TO THE TERMS ABOVE.