W. DENNIS PARKER STATEMENTS OF DISCLOSURE
Dennis is a Certified Clinical Hypnotherapist registered with the American Council of Hypnotist Examiners since 1991, (CHT 191-219). He is a Board Certified Hypnotherapy Examiner, Instructor, and Approved School Operator. He is a noted motivational/inspirational Public Speaker, Sales Trainer, and Hypnotherapist. He does various Seminars and Workshop Trainings on a variety of subjects, through his “Mind Management”, courses forprofessional athletes and coaches, corporate sales events, and convention seminars/workshops.
Dennis is an owner and operates “Certified Hypnotherapy Training School” as a Postsecondary Proprietary School of Hypnotherapy in the State of Utah, registered and bonded with the Department of Commerce. The School trains individuals in hypnosis, self-hypnosis, and hypnotherapy to be Certified Hypnotherapists and Certified Clinical Hypnotherapists through the American Council of Hypnotist Examiners.
His approach to life is that we all have unlimited potential to grow and develop our abilities and learning skills. He teaches people how to be free of fear, anger, guilt, and other negative emotions. He assists people to discover, recognize, and overcome self limiting beliefs, inappropriate habits, and maladaptive behaviors, which are keeping them from personal achievement.
He views his position as a teacher of mental skills and processes giving experience to the learner, which allows them to make new conscious choices about themselves and their goals. His easy manner of instruction and guidance empowers people to go beyond their current selves and reach levels of accomplishment only wished for before.
Dennis utilizes what he teaches in all areas of his trainings and instruction in daily real world applications. His seminars and workshops are enhanced by his years of experience of working with people in their personal lives, and developing their career performance. Assisting people to achieve their goals and being part of the success of others is a key motivator for him.
STATEMENTS OF UNDERSTANDING
Confidentiality Confidentiality will be strictly maintained except for the following circumstances: (1) with your permission and a signed release of information to a particular person or agency. (2) By law, any report of physical, sexual abuse, or neglect of a minor, or abuse of spouse or an elderly person. (3) If I have reason to assume that you may harm yourself or another person. I use a cell phone so that I am accessible, which cannot be considered 100% secure. Initials______
Payment for Services
Payments are to be made immediately following each session. Insurance carriers in the State of Utah do not as a practice cover these therapy sessions. I understand I am personally responsible for payments. Initials__________ To get the most from each session, it is recommended you arrive 10 minutes early to complete a preparation forms. Fees for the various sessions are available from the office or at: http://certifiedhypnotherapytraining.com/Fees.html
Cancellation of appointments
On occasion, a situation may arise which prevents you from keeping your scheduled appointment. Please notify me
24 hours in advance of your appointment if you cannot keep it. Except in emergency situations, you will be expected to pay for any sessions that you miss without this advanced notice. If you cannot provide 24 hours advance notice,
you have purchased the time as it was reserved for you, and will be billed accordingly. Initials__________
Ø I have received a copy of the statement of disclosure. I have read and understand the information provided.
Ø I have been informed of the terms of confidentiality and agree to them as stated above.
Ø I agree to pay for each session at time of service.
Ø I have read the above information, and understand that I am encouraged to ask questions, and give input regarding the hypnotherapy process at any time. If there is anything in this form that I do not understand, it is my responsibility to seek clarification. Initials__________
WE RESERVE THE RIGHT TO REFUSE HYPNOSIS AND HYPNOTHERAPY SERVICES AND TRAINING TO ANYONE. WE DO NOT WORK WITH DRUG ADDICTIONS, ALCOHOLISM, AND DIAGNOSED MENTAL DISORDERS. Initials______________
I UNDERSTAND THAT IF I AM CURRENTLY WORKING WITH A MEDICAL OR MENTAL HEALTH CARE PROVIDER AND HAVE BEEN DIAGNOSED WITH A MEDICAL/MENTAL DISORDER, AND I AM TAKING PRESCRIPTION DRUGS FOR THE DISORDER, AND SHOULD I WANT TO WORK ON A BEHAVIORAL MODIFICATION ISSUE, WITH HYPNOTHERAPY, I AM RESPONSIBLE TO INFORM MY MENTAL/OR OTHER HEALTH CARE PROVIDERS AND EXPLAIN TO THEM WHAT I AM CONSIDERING DOING WITH HYPNOTHERAPY. WE PREFER THAT YOU BRING US A PRESCRIPTION FROM YOUR HEALTH CARE PROVIDER TO HAVE US WORK WITH YOU FOR BEHAVIORAL MODIFICATION WITH HYPNOTHERAPY.
IF THEY HAVE QUESTIONS, PLEASE DIRECT THEM TO: www.certifiedhypnotherapytraining.com
OR HAVE THEM CONTACT DENNIS DIRECTLY TO ANSWER QUESTIONS OR CONCERNS: PHONE: (801) 628-0693. THESE PROCEDURES ARE STANDARD OPERATING PRACTICE, AND ARE DONE ON A ROUTINE BASIS. Initials______________
I HAVE __________ HAVE NOT _________ ATTENDED INDIVIDUAL OR GROUP HYPNOTHERAPY SESSIONS AND/OR WORKSHOP TRAININGS WITH W. DENNIS PARKER BEFORE. (Please put an x in the appropriate box.) Initials______________
I HAVE REGISTERED TO ATTEND INDIVIDUAL HYPNOTHERAPY SESSIONS AND/OR GROUP SETTINGS OF HYPNOSIS, SELF-HYPNOSIS, AND HYPNOTHERAPY, OR TRAININGS, WITH W. DENNIS PARKER. I STATE AND UNDERSTAND THAT I HAVE BEEN DULY ADVISED AND INFORMED THAT HYPNOTHERAPY SESSIONS DONE IN INDIVIDUAL AND/OR GROUP SETTINGS, COULD BE A VERY INTENSE PERSONAL EXPERIENCE. I UNDERSTAND AND WARRANT THAT I AM PHYSICALLY, MENTALLY, AND EMOTIONALLTY CAPABLE TO PARTICIPATE IN THESE HYPNOTHERAPY SESSIONS, AND WORKSHOPS. Initials____________
WE MAY DEEM THAT GROUP HYPNOTHERAPY SESSIONS ARE NOT THE APPROPRIATE SETTING FOR YOU, AND ASK YOU TO DO INDIVIDUAL HYPNOTHERAPY SESSIONS. OR, SHOULD WE FEEL THAT WHAT YOU AS THE CLIENT NEEDS OR REQUIRES IN SERVICES IS BEYOND OUR SCOPE OF SERVICE AND PRACTICE, REFER YOU TO SEEK OTHER ASSISTANCE. Initials______________
WE RESERVE THE RIGHT TO HAVE ANYONE LEAVE GROUP HYPNOTHERAPY SETTINGS, AT OUR DISCRESSION FOR ANY REASON. ESPECIALLY SHOULD YOU BE DISRUPTIVE, NON-SUPPORTIVE OF OTHERS IN THE GROUP, OR IN ANY WAY VIEWED AS BEING DETRIMENTAL TO THE SUCCESS OF THE GROUP, OR THE CREATION OF A POSITIVE, ENVIROMENT, ATTITUDE, AND HEALTHY, HEALING ATMOSHERE. Initials______________
IF FOR ANY REASON YOU ARE ASKED TO LEAVE THE GROUP AND YOU HAVE PREPAID THE SESSIONS, WE WILL REFUND THE PORTION OF THE SESSION PARTICIPATION THAT IS NOT YET ACCOMPLISHED. THERE IS NO REFUND FOR SECOND GROUP PARTICIPATION, IF IT IS BEING ATTENDED FREE, AS PART OF OUR GUARANTEE. Initials______________
Client Signature:_____________________________________ Date: ________________
Parent or Guardian Signature: _____________________________________ Date: ________________
Provider Signature: _____________________________________ Date: _____________________
Please download the entire Client Intake Form and have it filled out and ready when you come to the Advanced Health Clinic for the first time, or Fill out the School Registration form for Student Enrollment, send them in or bring them with you.