Intake Form

“You were put on this earth to achieve your greatest self, to live out your purpose, and to do it courageously.” ― Steve Maraboli

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Hypnotherapy clients, please note. Contact Lens: During hypnosis your eyes will be closed for about 45 minutes. If your contacts will cause eye irritation, remember to remove them before the session.
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NOTE: the services I offer are not meant to be substitutes for psychological or professional counseling. Hypnosis is not talk therapy; if you have an ongoing mental or medical condition, please consult a professional licensed by the state you live in.
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Contact Information: My name is Adrian Parks, Certified Hypnotist C.Ht.
I can be contacted through my website, holisticcmindguru.com or by telephone 310.735.0455

Education and Training: I was trained in Transpersonal Hypnotherapy, Neuro Linguistic Programing (NLP) and Spiritual Life Coaching at Southwest Institute of Healing Arts and became a Certified Hypnotherapist.

REQUIRED NOTICE: as the state of California has not adopted any educational and training standards for the practice of hypnotism, this statement of credentials is for informational purposes only.

Hypnotism is a self-regulating profession and its practitioners are not licensed by state governments. I am not a physician or a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. 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 the right to refuse hypnotism 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 sessions, and may assert any right without retaliation. Adrian Parks, C.Ht. does not treat, prescribe for, or diagnose any condition and is a properly trained facilitator of hypnosis and is not practicing any other profession that requires a license under the laws and regulations of the State of California. Hypnosis is not considered nor is it a Psychological treatment. Hypnosis for subclinical purposes requires no referral.

Fees: The charges for my services are: $115.00 for initial session maximum of 2 Hours. Discounts apply for services with 2 or more sessions: $85.00 follow-up for General Hypnosis session maximum of 1 Hour; separate pricing for group sessions and strictly Life Coaching Sessions. Payment are made online after confirmation of appointment. The user purchasing a service through the website has the right to cancel the service with prior written notification within a 24-hour period. There will be no refunds once service has been provided. All prices are subject to change without notice.

The current fees will be honored for 6 months.

Cancellation Policy: My time is my income and my hours are by appointment. Your time slot is reserved exclusively for you. Please arrive promptly to obtain your full session. A 24-hour cancellation notice is required, except in an emergency or inclement weather. If you must cancel or reschedule due to an emergency, please notify me as soon as possible. Thank you for your consideration.

Prepaid Sessions: The above Cancellation Policy also applies to any programs with prepaid sessions. Except for emergencies or bad weather, 24- hours’ notice is required. Failure to keep your appointment or non-emergent short-notice cancellations may result in the forfeiture of a prepaid session. No refunds will be given for unused prepaid sessions. All prepaid sessions are non-transferrable and will expire after six months.

Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record or a summary of my record about you.

MINORS: Appointments for children under age 18 require written consent from the parent or guardian, who must accompany them at each visit.

INSURANCE: I do not file insurance or any other third party claims. Insurance companies usually consider hypnosis as an alternative therapy and therefore do not cover it.

Medical Hypnosis: Hypnosis is effective in relieving some medical conditions (i.e., pain management, migraines, IBS, etc.) but will require a signed release from your doctor or appropriate health care professional to avoid masking symptoms before proper diagnosis and/or medical treatment has been obtained. Please see Hypnosis for Medical Conditions for more information and a convenient release form. Of course, non-medical issues (i.e., smoking, weight loss, confidence, etc.) will not need a form.

My approach: I believe that individuals have the right to choose or practice alternative or complementary self-improvement services. Hypnosis is safe and non-invasive. The services I render are held out to the public as a form of motivational coaching and education. I do not represent any of my services as any form of health care, psychotherapy or counseling. Hypnosis is not meant to be a substitute for psychological or professional counseling. If you have an ongoing mental health problem, please consult a professional licensed in the you reside in. I use hypnosis for past life and/or age regression and to motivate clients to eliminate negative or unwanted habits, facilitate the learning process, improve memory and concentration, develop self-confidence, eliminate stage fright, improve athletic ability, reduce/manage stress, focus on positive thoughts and desired outcomes, and for other social, educational and cultural endeavors. In general, I help people cope with the normal problems of everyday living by utilizing various techniques of hypnosis and progressive relaxation. Most hypnosis is of a non-medical nature. Despite research to the contrary, by law I may make no health benefit claims for my services. However, hypnosis does reduce stress, which is a beneficial adjunct for many medical and mental health disorders. Relaxation techniques can be learned which can reduce discomfort and improve certain health issues. I believe that thoughts and attitudes can influence how we feel and that hypnosis can help you change habits, focus on the positive, and visualize a state of wellness.

NOTE: Clients who use Holistic Mind Guru services understand in its entirety that the services and products offered are strictly spiritual in nature and do not under any circumstances claim to be medically therapeutic in nature. Additionally, the scope of business with emphasis on Hypnosis and any and all practices associated with Hypnosis is also widely based on a spiritual nature and does not in away serve to provide medical counseling and/or be a medical practice or therapy.

GUARANTEE AND REFUND POLICY: No guarantees as to the effectiveness of hypnosis for your particular problem are made or implied, as it is impossible to guarantee human behavior or compliance. Therefore, no refunds for services are given. Hypnosis is not a quick fix or magic pill. A hypnotist is considered a guide or facilitator. You assume equal responsibility by making a commitment and allowing yourself to be guided into a state of hypnosis. No one can make you do something against your true will. I sincerely want you to succeed and pledge my efforts to help you to the best of my ability.

I HAVE READ THIS CLIENT BILL OF RIGHTS AND I FULLY UNDERSTAND WHAT I HAVE READ. I acknowledge receipt of a copy of this statement for future reference.
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I have been advised by Adrian Parks the scope of hypnosis practice and I give my full consent to receiving hypnosis sessions or any other services provided by Adrian Parks. I understand that results vary and that the above name practitioner may not guarantee results. Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling. I also understand that the Hypnotist does not treat, prescribe for or diagnose any condition. I understand that the practitioner is a facilitator of hypnosis and is not practicing any other profession that requires a license under the laws of the State of California.  

I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability. I have accurately provided background information as requested by the hypnotist.

I understand that confidentially regarding my sessions will be honored between my hypnotist and me. This same confidentially is respected when working with minors under the age of eighteen.
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