I am responsible for giving full details regarding my health. The above information is complete and accurate. I will notify Samantha Dove of any changes to my health or medication immediately. I understand that my consultation and any subsequent therapy shall remain confidential except in situations where legal statute requires appropriate authorities to be notified. I agree that because people are individual and unique, there can be no guarantees regarding the outcome of any treatment, and I therefore agree that Samantha dove accepts no liability in this regard. I confirm that I realize that to get the best results, I need to work in a collaborative way with Samantha and I understand that my full co-operation and positive input is required to obtain those best results. I understand that I am paying for Samantha Doves time and not for a guaranteed success. I understand that Hypnotherapy, or any other therapy provided by Samantha Dove is not a replacement for medical treatment, psychological or psychiatric services or the appropriate counselling. I also understand that Samantha Dove does not treat, prescribe for, or diagnose any medical or mental health condition. I understand that any mp3 download/CD is provided for me at Samantha Dove’s discretion. I agree that any such mp3 download or CD is for my personal use only and that it is not to be lent, copied, or sold under any circumstances. I hereby consent to this consultation and any subsequent treatment.
Confidentiality
As a registered member of the General Hypnotherapy Register (GHR) I abide by their Code of Ethics. Matters discussed between us will remain confidential. The exceptions to this confidentiality clause are if:
I believe you or someone else is at risk of serious harm
I hear of harm or abuse to a child
I am ordered by a court of law
I become aware of an act of terrorism
If I believe you are at risk of harming yourself, I will consider contacting your GP or Local Crisis Team. I would make every effort to discuss any concerns I have with you first.
In accordance with best clinical practice, I discuss my work with a supervisor. My supervisor is bound by the same code of confidentiality and ethical framework.
Data Protection Act
Any personal details I keep are stored securely. Under the terms of the general data protection regulations and the 1998 Data Protection, you must give your consent to such information being made and retained. By signing this agreement, you are giving such permission for myself to collect and process the above information and any information that is shared within our sessions The legal reason for this is for the pursuance of both my own and your legitimate interests. I have read, understood and I accept your Privacy Notice.