WHEREAS, Bruce C. Terrill, on behalf of Northwest Hypnosis Institute ("NWHI"), agrees to provide hypnosis services, life coaching or business consulting services in accordance with acquired education and training to the undersigned (the “Client”) for good and valuable consideration from Client;

NOW THEREFORE, Bruce C. Terrill represents the following to Client regarding the services offered:

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Contact Information:

My name is Bruce C. Terrill.  I can be contacted through my office at Northwest Hypnosis Institute, Inc., 10175 SW Barbur Blvd (Suite 204-C), Portland, Oregon 97219 or by telephone at (503) 267-1675.  My email address is talkwithbruce@gmail.com.

Education and Training:  

I trained in hypnotism at the Knightsbridge Institute and received Consulting Hypnotist Certification from the National Guild of Hypnotists;

I received training and certification as a Certified Hypnotherapist and specialized in Conversational Hypnosis from The International Association of Professional Conversational Hypnotists;

I received training and certification as a Certified Instructor of Hypnotism from the National Guild of Hypnotists;

I received training and certification as a Neuro-Linquistic Practitioner from Beverly Martin, Master Practitioner; and

I own and operate the Northwest Hypnosis Institute, Inc.

Affiliations:

I am a member of the Oregon Hypnotherapy Association;

I am a Certified Member of the National Guild of Hypnotists.  The National Guild of Hypnotists is the oldest and largest hypnotism organization in the world and its certification is the most widely recognized credential for the professional practice of the hypnotic arts.  

I am a Certified Member of The International Association of Professional Conversational Hypnotists.

I am a former member of the Association for Professional Hypnosis and Psychotherapy, London, United Kingdom.

Notice:  

THE STATE OF OREGON HAS NOT ADOPTED 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 the state. I am not a physician or a licensed health care provider. I do not provide medical diagnoses, prescribe medications or recommend a course of medical treatment. My credentials do not imply any form of federal, state or local governing body licensing or education in any professional medical, health, therapeutic, emotional counseling, psychiatric, psychological or sociological field. I maintain our communications in confidence. However, communications with me are not privileged communications such as those with your medical provider.‍

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Client Rights:

1. Client may discontinue hypnotic services at any time.
2. In the even Client terminates hypnotic services with NWHI, Client has the right to a coordinated transfer of services to another practitioner.
3. Client has a right to refuse hypnotism services at any time.
4. Client has a right to be free of physical, verbal or sexual abuse.
5. Client has a right to know the expected duration of sessions.
6. Client may assert any of the above rights without retaliation.

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Redress:

I am a certified member of the National Guild of Hypnotists, and practice in accordance with its Code of Ethics and Standards.  If you have a complaint about my hypnosis services or behavior that I cannot resolve with 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.  

Fees:  

I charge $150 per hour for hypnotic services. However, those rates may vary depending on the services that I am performing. The NWHI Services Agreement will control the agreement between NWHI and Client. A hypnotic session is typically 60 to 90 minutes in duraton. Clients will be given thirty (3) days notice of any change in fees. Payment options include cash, check PayPal, and most major credit cards. Generally, insurance companies do not cover hypnotism services and as a result, I am unable to process insurance, including Medicare claims at this time.

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No-Show/Late-Cancellation Fee:  

All appointments must be cancelled twenty-four (24) hours prior to the scheduled appointment to avoid a $75 cancellation fee. This includes arriving late to a scheduled appointment. Clients must call and leave a message at (503) 267-1675 to cancel an upcoming appointment. NWHI reserves the right to waive any Late-Cancellation Fee.

Confidentiality:  

I will not release any information to anyone without a written authorization from you, except as required by law.  Our communications are not subject to or protected from disclosure as a result of the doctor-patient or any other form of privilege. You have a right to your file including my professional notations about you regarding the services you have received. NWHI reserves the r ight to charge a reasonable copying fee for requested files. NWHI supports mandatory reporting of child abuse.

My Approach:  

Hypnotism means the use of trance and suggestion to adjust habits of thought, feeling and behavior.  I use hypnotism with clients to motivate them to eliminate negative or unwanted habits, facilitate the learning process, improve memory and concentration, develop self-confidence, eliminate stage fright, improve athletic abilities, maximize skills and for other social, educational and cultural endeavors of a non-medical nature.

Services:  

The services I render are nontherapeutic hypnotism, defined as the use of hypnosis to inculcate positive thinking and the capacity for self-hypnosis.  I am not a health care provider. I do not provide any form of healthcare seervices including mental health services such as psychotherapy, psychology or counseling. I do not diagnose, treat or cure mental health disorders. I reserve the right to terminate any hypnotic session with Client for any reason in my sole discretion, or refer Client to a different hypnotist terminating the services by NWHI.

The successes using my services and forms of treatment are dependent on many variables, including attitude, motivation, cooperation, practice and the attendance of scheduled sessions. I make no representations, warranties or guarantees about the Services I provide. To achieve the best results, Client must agree to hypnosis, and follow through with my recommendations, if any.

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Acknowledgement:  

I, the undersigned Client acknowledge that I have received a copy of this Client Disclosure and by signing attest that I have read and understand the information provided, and that I consent to e-sign this agreement.