Declaration Form for Therapy.
Please read carefully.
- I understand the nature of shiatsu massage / foot reflexology / hot stone massage / sports massage / clinical hypnotherapy. The therapy has been explained to my satisfaction
- I understand the probable duration of the therapy, or the estimate of the number of therapy sessions required for treatment. This has been explained to my satisfaction
- I have agreed upon a specific outcome for therapy
- I understand that a guarantee of a successful outcome is not possible, and accept that even though the therapist carries out this treatment flawlessly, the specific result may not be achieved due to circumstances outside the therapists control
- I understand that there is a fee for treatment and agree to pay this in the manner agreed before treatment begins
- I have disclosed all information which might affect the outcome of treatment or my well being
- I understand everything discussed is confidential. The only time confidentiality would be broken is if the therapist has reason to believe that myself or someone else might be at risk
- I understand that treatment for pain management will only be undertaken after a medical/GP referral or diagnosis. I understand GP consent is required prior to treatment for the following symptoms: panic attacks, headaches, migraines, skin conditions, asthma, dystonia and IBS.
- I acknowledge and understand that my personal data will be collected for treatment purposes and this information is stored in accordance with the General Data Practice Regulations (GDPR). I have been informed of GDPR and directed to my therapist’s website for reference
- I give my consent to email/text for appointment bookings and confirmations, hypnosis (not therapy) recordings and requests for feedback on treatments
- I understand that under UK Tax Law my basic personal data will be retained for a minimum of 6 years, after which time it will be destroyed
- I understand a paper copy of my records is available on request, and would be provided free of charge within 30 days
- For more information on GDPR: https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/
- For online hypnosis I understand Zoom is the preferred platform as it has end to end encryption. I may choose an alternative online platform I am comfortable with. It is my responsibility to ensure I have adequate anti-spyware and anti-virus protection
- I give my consent for this therapy
Please download treatment declaration here, sign it and bring it to your first appointment, if you are in full agreement with its contents.