Hypnoteyes

Hypnotherapy & Holistic Healing

Heal the Root. Not the Symptom.

New Client Intake & Consent Packet

Sarah Jane Riley, CHt, QHHT · Reiki Master · Shamanic Practitioner
24100 Rialto Way, Sorrento, Florida 32776 · 407-494-3578

Please read this packet in full and complete the form below before your first session. A copy of your responses will be kept in your confidential client file.

1. Practitioner Disclosure

My name is Sarah Jane Riley, CHt, QHHT. I can be contacted at the office address and telephone number above.

Education and Training

I trained in hypnosis at the British School of Yoga in England, where I attained my A.M.I.H. qualification (Associate, Midlands Institute of Hypnotherapy). I have completed a course in Neuro-Linguistic Programming and hold certification as a Clinical Certified Hypnotherapist. I am a QHHT practitioner, Reiki Master, and Shamanic Practitioner. I continue to develop my qualifications through ongoing education.

Regulatory Notice

As the State of Florida has not adopted educational or training standards for the practice of hypnotherapy, this statement of credentials is for informational purposes only. Hypnotherapy is a self-regulating profession, and its practitioners are not licensed by state governments. I am not a physician or a licensed healthcare provider, and I do not provide a medical diagnosis or recommend discontinuation of any medically prescribed treatment.

As a client, you have the right to:

Refuse hypnotherapy, Reiki, or Shamanic services at any time, without retaliation.
Be free from physical, verbal, or sexual abuse.
Know the expected duration of your session in advance.

2. Fees & Cancellation Policy

Standard hypnotherapy, Reiki, and Shamanic sessions are charged at $125 per hour, billed in 15-minute intervals.

QHHT sessions are booked separately, with their own intake and consent page — see the QHHT page for QHHT-specific fees, session length, and recording consent.

Fees are due at the end of each session, payable by cash, check, Zelle, or credit card. You will be given 14 days' notice of any change in fees.

Cancellation Policy

I require 24 hours' notice to cancel or reschedule an appointment. Sessions cancelled or missed without this notice will be charged in full.

3. Confidentiality

I will not release any information about you to anyone without your written authorization, except where required by law. You have the right to access my written records about you.

I recommend you plan to pay for these services personally rather than through insurance. No insurance companies cover hypnotherapy, Reiki, or Shamanic services.

4. Informed Consent — Hypnosis, Reiki & Shamanic Practice

Hypnosis is not a state of sleep, but a natural state of focused relaxation of mind and body. Reiki and Shamanic practice are gentle, complementary energy modalities intended to support relaxation and the body's own capacity to restore balance. None of these are a substitute for medical or psychological care, and none diagnose, treat, or cure any medical or psychiatric condition.

By participating, you acknowledge:

You are participating by your own choice.
You are a co-operator in this process, not a patient.
Your progress depends on how you care for yourself physically, mentally, emotionally, and spiritually.
Transformation is a process, and it can take time.

5. Client Intake Form

Full name

Address

City

State

Zip

Date of birth

Age

Cell phone

Emergency contact name

Relationship

Emergency contact phone

How did you hear about Hypnoteyes?

Reason for your visit

Have you been in therapy before?

Yes No

Been hypnotized before?

Yes No

Are you currently taking any medication? If yes, for what reason?

Please bring with you to your consultation

A written list of any traumatic events, accidents, and surgeries, together with the approximate age you were when each one happened. This helps Sarah understand where things may have taken root, and makes your session far more productive.

If you are under 18, this form must be completed and signed by a parent or legal guardian.

6. Acknowledgement & Signature

By submitting this form, I confirm that I have received, read, and understood the Practitioner Disclosure, Fees & Cancellation Policy, Confidentiality information, and Informed Consent sections above, and that all of my questions have been answered to my satisfaction.

I acknowledge that I will give 24 hours' notice if I need to cancel or reschedule my appointment, and that if I do not, I will pay the full price of the session scheduled.

Type full name as signature

Date

Parent/Guardian signature (if client is under 18)

As your practitioner, I commit to using all of my skills to help you reach your goals in the shortest time possible.
You have my assurance of full integrity, professionalism, confidentiality, and respect.

— Sarah