I (Client) _________________________________________________________________________
hereby release Anne M. Wrinn 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 Anne M. Wrinn is a Certified Hypnotherapist and is not a licensed physician, psychologist, or medical practitioner and that hypnosis should not be considered as a replacement for the advice and/or services of a psychiatrist, psychologist, psychotherapist or doctor.
I give Anne M Wrinn 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.
I understand that although Rapid Transformational Therapy has an incredibly high success rate, Anne M. Wrinn cannot and does not guarantee results since my own personal success depends on many factors that she has no control over, including the strength of my desire to create change within myself and my commitment to listening to the sound file for 21 days.
I give Anne M. Wrinn 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) Anne M. Wrinn retains full copyright over any forms of media that may be produced and distributed to me.
I hereby give Anne permission to (if in an in-person session) respectfully lift my arm, touch my shoulder, or rock my head during my RTT session in order to help facilitate the deepening process.
By signing this form, I consent that Anne 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, Anne may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise.
____________________________________________________________________________________ Full Name Signature Date