Client Information
and
Agreement Form

Please take five minutes to fill out and read this form after booking your session.

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Marital Status

Number of children:

How did you find out about Maria?

Have you ever been hypnotized before?

I voluntarily agree to sign this agreement and assumption of risks, because I fully understand that Maria Camia, who is going to perform hypnosis, is not a doctor, nor has a degree in Psychiatry, and can neither diagnose nor treat any type of physical or mental disorder. 1. I am participating in hypnosis by my own choice because I want to be here. 2. I understand that I am not a patient, but a co-operator in my hypnosis experience. 3. I understand that any suggestion that is made during this session is only part of a personal and education motivation program, and is only informative. 4. I understand that my progress here involves how I care for myself physically, mentally, emotionally, and spiritually. 5. I understand that this hypnosis session is exclusively for educational or emotional reasons. It is not intended to be in any way used as medical or psychological advice, this can only be given by a medical professional or a mental health specialist. 6. I understand that transformation is a process and that it can take time. *DISCLAIMER: Hypnosis is not intended to cure any specific condition. I make absolutely no claims of a cure for any disease. Individual results may vary. Each session is unique and its success depends on your cooperation and faith in the process. 1. I am willing to be guided through relaxation, visual imagery, hypnosis, and/or stress reduction techniques. I am aware that these modalities are spiritual-based and non-medical in nature and it is my responsibility to consult my regular doctor about any changes in my condition or changes in my medication. 2. I understand the above modalities are not substitutes for regular medical care and I have been advised to consult my regular medical doctor or health-care practitioner for treatment of any old, new, or existing medical conditions. 3. I understand that being hypnotized is not being asleep. During a deep hypnotic trance, you can open your eyes, speak, laugh, walk and you may be aware of everything that happens around you. You can even open your eyes and think it is not working and are not hypnotized. But when you allow those feelings or thoughts that come to your mind to flow freely as Maria Camia speaks to you, you will relax and remember forgotten events in this life or a past life. 4. I understand that change is my own and complete responsibility. I understand that all healing is self-healing and that Maria Camia is only a facilitator in the process of helping me to solve my own problem(s). It is my responsibility to be open and honest, provide accurate feedback and be forthcoming with details and information that may help me achieve my outcomes. 5. I understand that our session will be digitally recorded for my later use and that Maria Camia retains the copyright of these recordings. I also understand that in these types of metaphysical sessions, the energy in the room can affect the equipment and recording resulting in static or blank recordings. 6. I understand that often in Hypnosis sessions, universal information is provided through the client to benefit all of humanity. I agree to allow Maria Camia to share this information and any accompanying story either on video or in written form in blogs or books as long as my first and/or last name and all personal and relevant details are omitted and/or changed. (On videos, you will agree on what to omit.) I am of legal age and understand I am entering into a cooperative relationship of my own free will. I accept that I am a willing participant in this cooperative relationship that will employ hypnotic techniques, regression, NLP and any other appropriate modality by Maria Camia. Therefore, I do hereby release and discharge Maria Camia from all claims of damages, copyright, demands or actions whatsoever in any manner arising from or growing out of my cooperative participation. Any concerns or questions can be addressed with the international Association of Interpersonal Hypnotherapists as the governing and credentialing body. I have received and read this Client Information and Agreement Form and understand what I have read.

Client Electronic Signature

By typing your name, you agree to the above information is true and understand what you read.

I commit to you that I will utilize all of my skills to help you. You have my assurance of full integrity, professionalism, confidentiality, and respect. All sales are final and no refunds will be given.