DAYDREAM HYPNOTHERAPY & COACHING DISCLOSURE FORM

The undersigned client acknowledges that they have been informed of the following information:

Hypnotherapist/coach agrees to provide professional services in accordance with acquired training and experience, giving undivided attention during scheduled consultations to facilitate client-centered sessions.

The therapeutic use of hypnosis can elicit information and insights from the deeper mind, and utilize the power of one’s inner resources. Hypnosis involves a relaxed mental state, similar to daydreaming, meditating, or being absorbed in a good book or movie. Many people experience a deep sense of calm, mental clarity, profound relaxation, and an enhanced ability to vividly imagine or visualize scenarios. In the hypnotic state, we have access to a part of our mind that is open to ideas and solutions. The client's attention is focused inward, while they still remain aware of what is going on in the world around them. The hypnotherapist utilizes interviews, discussion, and hypnotic methods dealing with underlying issues whenever appropriate, with the goal of achieving effective and lasting results. Hypnotherapy can help clients discover their inner creative abilities to develop positive thinking and feeling and to transform undesirable habits, beliefs, and behavior patterns. Therapeutic goals are to achieve freedom from restrictive thought and belief systems, to cultivate inner resources for solving problems, facilitating self-healing, restoring the authentic self, developing motivation, achieving goals, and fulfilling potential.

Coaching involves partnership between the coach and the client in a thought-provoking and creative process that inspires the client to fulfill their potential, gain self-understanding and insight, live authentically, examine and potentially re-write life scripts, improve relationships and communication skills, practice self-care, and set healthy boundaries. It is designed to facilitate the creation/development of personal, professional, relationship, or life goals and to develop and carry out a strategy/plan for achieving those goals.

Client is solely responsible for creating and implementing their own physical, mental, and emotional well-being, decisions, choices, actions, and results arising out of or resulting from the hypnotherapist/coach and client relationship. Services to be provided do not include the practice of medicine or psychotherapy. Hypnosis and coaching are non-diagnostic, and are not a substitute for medical treatment, but a complimentary modality that engages the mind, body, and spirit for optimal healing, performance, and well-being.

Mimi Pettibone is a certified hypnotherapist and coach and has acquired the following education, training, experience, and qualifications to perform the services offered to her clients:

• Certified & Registered Clinical & Transpersonal Hypnotherapist, credential # 60158793
• Certified: Guided Imagery Practitioner, NLP Practitioner (Neuro-Linguistic Programming), Sleep Coach, Master Level Dream Worker, and Meditation Facilitator
• Certified Transactional Analysis Practitioner (270 hours training) by the United States of America Transactional Analysis Association (USATAA). T.A. is a social psychology of relationships, communication skills, intrapsychic communication, games, and life scripts.
• Attachment, Trauma, & Spirituality (1-year training) with Dr. Diane Poole Heller
• Additional training: Advanced Voice Dialogue Facilitator, Gestalt Practitioner, Focusing Facilitator, Shadow Work, and programs taught by Dr. John Gottman (relationships) and Dr. Bessel van der Kolk (trauma)
• Certified Telehealth Practitioner

Mimi Pettibone is a certified telehealth practitioner. If you wish to record your session and the meeting is via video, it is recommended to use a separate device to record audio as video conferencing platforms may not be HIPPA compliant due to how they store recordings.

I have received a copy of this disclosure and understand the information described above. I have also read of the hypnotherapist/coach’s education, training, experience, and other qualifications regarding the services to be provided.