Service Agreement
I, _________________________________, agree that any scheduled visit with Olathe Hypnosis Center LLC constitutes a retainer of time and I agree to pay Olathe Hypnosis Center LLC a retainer fee of $225.00 per session (50 minute) for any such scheduled visit or I am purchasing a prepaid package of 4 sessions (50 minute each) for $697.00 or 10 sessions (50 minute each) for $1597.00

I acknowledge that if I purchase a prepaid package, the prepaid packages are non-refundable. __________ 

In the event that I need to change or cancel a scheduled appointment with Olathe Hypnosis Center LLC, I agree to give Olathe Hypnosis Center LLC a 48 hours notice of said changes or cancellation. In the event that I do not give 48 hours notice of a change, I agree to pay Olathe Hypnosis Center LLC a cancellation fee OF THE FULL RETAINER for any time retained or scheduled. ____________

I also authorize Olathe Hypnosis Center LLC to charge the credit card I have on file to pay for any such retainers. I understand that payment is due on or before any such scheduled visit or a 15% service charge may be added to the retainer fee.

I also understand that Olathe Hypnosis Center LLC members are not licensed medical doctors or licensed mental health providers (psychologist, LCSW, LCT, etc). The services rendered by Olathe Hypnosis Center LLC are non-diagnostic and do not constitute the treatment of any physical or mental health disease or disorder.

I also understand that the primary purpose of this program is for vocational or avocational self-improvement. I also understand that results vary from client to client and that no guarantees have been made as to the outcome of this ongoing self-improvement program.

I also understand that during hypnotic sessions it is possible to create false memories or other known and unknown side effects and Olathe Hypnosis Center LLC has disclosed this risk to me and I accept this as an acceptable risk in regards to this program of vocational or avocational self-improvement and I hold Olathe Hypnosis Center LLC harmless for any false memories or other known and unknown side effects that might result from said program.

Olathe Hypnosis Center LLC keeps all client information confidential and will not share any client information with any third party without my written permission except to obtain payment or to communicate critical information to a medical or psychological professional in the event of an emergency, in the event of the risk of harm to myself or others or subpoena.

I do authorize Olathe Hypnosis Center LLC to contact me by email, phone, or text message to remind me of my scheduled visits.

Yes 𐄂 No 𐄂 I authorize any case information and recordings to be shared with Olathe Hypnosis Center LLC mentors or future students for training purposes.

My signature on this document constitutes my acceptance of this privacy notice and my authorization to bill my credit card on file.

Notes:
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Printed Name _________________________________________________________________________
Signed Name and Date _________________________________________________________________________
Signature of Parent or Guardian _________________________________________________________________________

Date_____________________________________________________________________