I, hereby release and indemnify, Virginia Rus, 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. By typing my full name below, I agree to these terms and conditions. I agree to indemnify and hold harmless Virginia Rus from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including legal costs and fees, brought as a result of my involvement in the therapy.
Scope of Practice:
I understand that Virginia Rus 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, or doctor.
I understand the nature of the sessions to be provided. I understand that Virginia is not a licensed physician and that it is my responsibility to maintain a relationship with my medical doctor if I so desire. If I use Transformational Therapy and am under medical care for ANY condition, I WILL NOT make any adjustments to any prescribed medication without the approval of my doctor. If I am in any doubt, I will contact my doctor/physician immediately.
I understand that if I am epileptic or suffer from a psychotic illness it is not generally recommended that I undergo hypnotherapy. I hereby agree that by signing this form that I do not currently suffer from these disorders.
Audio Radio Recording(s):
I indicate that I agree to give Virginia Rus full permission to make an audio recording that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s) Virginia Rus retains full copyright over any forms of media that may be produced and distributed to me. I understand that having a recording made of part of my session and my willingness to listen to the recording for 21 days will contribute to my success.
I agree to allow Virginia Rus permission to make an audio recording that may include my voice to be used in my treatment
I indicate that I agree to give Virginia Rus full permission to hypnotize me and to use 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 agree to listen to the personalized recording for full 21 days.
I agree to be hypnotized by Virginia Rus using Transformational Therapy.
I agree to participate fully in the session.
I hereby grant permission to Virginia Rus to guide and direct me, during my Transformational Therapy session (s) by telling me to raise and drop my arms on my laps, rock my head, in order to help facilitate the deepening process.
I understand that although Transformational Therapy has an incredibly high success rate, Virginia Rus cannot and does not guarantee results since my own personal success depends on many factors that Virginia Rus has no control over, including my willingness and desire to affect the changes inside of myself.
By signing this form, I consent that Virginia Rus 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, in imminent danger to myself or others; or if a subpoena of records has been requested. I also understand that, at any time, Virginia Rus may discuss aspects of my case with other colleagues keeping my name and identity completely confidential always unless I have given permission otherwise.