Welcome to Your Journey of Healing with Donna

I am looking forward to working with and helping you accomplish your goals. The first step is to complete the online paperwork right below. The most important page is the "How Will Your Life Be Great" page. This is where you will communicate the benefits of accomplishing your goals. This is all about you, so take your time and give yourself the gift of your attention, to set positive intentions. ~Donna

Wise Mind Hypnosis New Client Form 2024

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WISE MIND HYPNOSIS - THE 2023 NGH CLIENT BILL OF RIGHTS - STATEMENT OF INFORMED CONSENT

Contact Information: Donna M. Bloom. Board Certified Hypnotist can be contacted by telephone at 516-933-3669. Location is 4250 Hempstead Turnpike, Suite 9, Bethpage, NY 11714.

Education and Training: As the State of New York has not adopted educational and training standards for the practice of hypnotism, this statement of credentials is for informational purposes only. I was trained in hypnotism at New York Hypnosis Training Center in Holbrook, NY (a New York State approved school.) Additional Training was received from the Banyan Hypnosis Center). I am a Certified Member of the National Guild of Hypnotists and I do annual continuing education to maintain my training at a high level. The National Guild of Hypnotists is the oldest hypnotism organization in the world and its certification is the most widely recognized credential for the professional practice of the hypnotic arts.

Scope of Practice: I provide meditative and motivational coaching for a wide range of issues, including making medical or psychological care obtained elsewhere more effective. However, my work is not intended as a substitute for such care. I do not diagnose, treat nor prescribe. My services help normal persons with normal problems in living, enhancing human flourishing by inculcating positive thinking by the capacity for self-hypnosis. My services are supportive and educational, teaching persons to use their natural skills and abilities.

Practice Limits: If a client desires a diagnosis or any other type of treatment from a different practitioner the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to coordinated transfer of services to another practitioner. A client has a right to refuse hypnosis or coaching services at any time. A client has a right to be free of physical, verbal, or sexual abuse. A client has a right to know the expected duration of our work together and may assert any right without retaliation.

Redress: I am a certified member in good standing with the National Guild of Hypnotists, and practice in accordance with its Code of Ethics and Standards. If you have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the National Guild of Hypnotists at P.O. Box 308, Merrimack, NH 03054-0308, (603) 429-9438, to seek redress. Every member of the National Guild of Hypnotists provides this information to every client to ensure ethical practice.

Investment Structure: Basic Investment Program Rate ($1500 for 4 sessions.) The first session is 2 hours and subsequent sessions are 75 minutes. Payment plans are available.) (Subsequent sessions at the client's discretion are $250.) As with other healing arts, the practice of hypnosis and hypnotism is not an exact science. Therefore, results are not guaranteed, nor are refunds given for services rendered. You may pay for services by check, cash, or credit card.

Confidentiality: I will not release any information to anyone without written authorization from you, except as provided for by law. Sessions are videotaped, held confidentially, and become the property of Wise Mind Hypnosis. You have a right to be allowed access to my written record about you.

Insurance: I suggest you think of my hypnosis services as something that you will pay for personally. That will both protect your privacy and help you value the work you are doing more. In general, insurance companies do not like to cover hypnotic services, and I caution you not to expect them to do so.

Exposure: An inherent risk of exposure to Covid-19 exists in any setting where more than one person is present. Our practice follows all recommended precautions and rules regarding protecting public health. However, you voluntarily assume all risks related to exposure to Covid-19 or any similar illness should you visit our facility in person rather than online.

My Approach: Assisting you in achieving your goals through the utilization of motivational hypnosis, mindset coaching and meditation practices.

Digital Client Signature - By Typing in Name, you agree to all terms.*

Appointment Policy

A personal promise and commitment from Donna Bloom, BCH, is made to every single client. Clients are expected to make a commitment to themselves, the work and attend their scheduled appointments.

During your private sessions, you will meet with Donna Bloom, a Board Certified Hypnotist. In these sessions, you will be taught hypnotic techniques which will help you take control over your own behaviors, feelings and attitudes. You will also be guided through hypnotic processes, personally tailored to overcome obstacles and help you achieve your goals. The first session will be approximately 2 hours. Each subsequent session will be 75 minutes in length.

“Hypnosis is a quick and effective way to naturally make changes, however, hypnosis is not mind-control. Because of this, we cannot guarantee results. There is always a human factor. Your success is dependent upon utilizing the skills, resources and reinforcement provided to you throughout the program. Ultimately, your success depends on you. You must be willing and cooperative to making the changes you desire. I do guarantee and promise to provide the very best service, using current information and appropriate hypnotic techniques for your situation, within the scope of practice.”

Success Agreement Appointment and Rescheduling Policy*

Rescheduling Policy: You have agreed to attend all sessions, and if you cannot keep a scheduled appointment, you agree to provide 2 business days (Monday – Friday) to reschedule, the appointment. If advanced notice is not given, that appointment will be considered a paid session. If you are paying by the session, your credit card on file will be charged for the missed appointment.

You will receive a confirmation email 72 hours prior to your appointment as a courtesy reminder. Please note: it will be a no-reply email. I understand Donna will NOT and CANNOT receive any replies to those emails. You must contact Donna directly to change an appointment, no exceptions or oversights.

RESULTS AGREEMENT*

“I understand that hypnosis is not meant to diagnose or treat any disease, but rather it is intended to provide information, education, and motivation that will promote better feelings, to help me achieve my goals. It is designed to give me insight and tools to reach my innate potential and guide me into being more effective in helping myself. I also realize that hypnosis is not a substitute for conventional medicine. By signing this, I am stating I have read this success agreement, I understand the reschedule policy and understand my results depend on me. Therefore, results cannot be guaranteed, nor are refunds given for services rendered. "By signing this, I am stating I have read this success agreement, I understand the reschedule policy and understand my results depend on me. Therefore, results cannot be guaranteed, nor are refunds given for services rendered."

Signature - To agree and comply with all terms.*

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Welcome to Your Journey of Healing with Donna

Wise Mind Hypnosis New Client Form 2024

WISE MIND HYPNOSIS - THE 2023 NGH CLIENT BILL OF RIGHTS - STATEMENT OF INFORMED CONSENT

How will your "LIFE BE GREAT" when you are completely past this issue or these concerns? Specify the change(s) you desire, to help you live your very best life.

Appointment Policy

Wise Mind Hypnosis, 4250 Hempstead Turnpike, Suite 9, Bethpage NY 11714 | Office: 516-933-3669