Zen Hypnosis 501(c)(3) Nonprofit Public Charity • EIN 39-5157747

Clinical Hypnotherapy Informed Consent & Sovereign Waiver

Governing Post-Secondary Practicum & Clinic Services • NUCC Taxonomy 101YA0400X

OFFICIAL
CLINICAL
SEAL
Clinic & Academic Headquarters: 401 5th Ave NW, Attalla, AL 35954 • Tel: (334) 402-3425 • Email: [email protected]
Executive Director & Supervisor: Daniel Carl Geary Jr., CCHt, CRSS • Alabama Counselor License #013182

1. Nature and Purpose of Clinical Hypnotherapy

Hypnotherapy is a collaborative, educational, and motivational process that utilizes guided focused attention, deep somatic relaxation, and subconscious cognitive reframing. It is not talk therapy, medical diagnosis, or prescription psychiatry. The client remains conscious, sovereign, and in complete control throughout each session.

2. Scope of Practice & Non-Medical Disclaimer

The practitioner does not diagnose mental disorders under DSM-5 or prescribe pharmaceutical drugs. Hypnotherapy under NUCC taxonomy 101YA0400X addresses behavioral change, stress reduction, pain attenuation, trauma resilience, and habit cessation. Clients with severe psychiatric symptoms must maintain concurrent physician or psychiatric supervision.

3. Confidentiality and Sovereign Autonomy

All clinical records, voice notes, and intake histories are held under strict confidentiality, subject only to mandatory legal reporting (imminent physical harm to self or others, or abuse of vulnerable persons). The client reserves the sovereign right to pause, redirect, or terminate hypnotic trance at any moment.

4. Acknowledgement and Electronic Signature

By signing below, I certify that I have read and understood this Informed Consent & Liability Waiver. I consent to receive clinical hypnotherapy services and/or participate in GIHA supervised practicum training.

Client / Scholar Signature
Date: October 27, 2026
Daniel Carl Geary Jr., CCHt, CRSS
Master Practicum Supervisor & Executive Director