Mind Wave Institute Informed Consent and Contract for Sessions with Dr. Cindy Sholes

Background and Approach: Cynthia Sholes, Ph.D., MdH (Dr. Cindy) has a doctorate from UCSF in Neuroscience (1996) and is a Professional Hypnotherapist. She was certified in Advanced, Clinical and Medical Hypnotherapy in 2001 from Palo Alto School of Hypnotherapy approved by Continuing Education by the Board of Behavioral Sciences, a Board within the California Department of Consumer Affairs.

Combining her continued education and over 20 years of experience with about 10,000 client hours, Dr Cindy created the rREST Technology which she combines with hypnotherapy to coach her clients for their self-improvement and personal growth. She provides hypnotherapy, guidance and other mind body therapies based on the client’s personal history and lifestyle, and on the latest scientific research.

No particular result or outcome is promised or guaranteed. Any and all results of the consultations are the sole responsibility of the client.

She does not practice bodywork. Nor is she a licensed physician, psychotherapist or other licensed health care provider. She does not treat or diagnose mental, emotional, medical, or psychological disorders. The State of California does not license Hypnotherapists or Hypnotists. I understand this Program is not psychotherapy and I am agreeing to proceed under these terms.

Sessions: Standard sessions are 50 min. to 1 hour. Sessions are designed with the client to meet individual needs. Each client receives a unique plan specifically tailored to their specific goals. No specific outcome or result is guaranteed.

Fees: The fee for a standard session is $450 per 50 min. session. The fee for an additional 30 min sessions fee is $225. The fee is due at the beginning of the visit unless a package of sessions has been purchased. Appointments missed, canceled or rescheduled with less than 24-hour advanced notice are subject to a $400 cancellation fee. You authorize Mind Wave Institute to charge your credit card on file.

For optimal results, a package of weekly or semi-weekly sessions is usually recommended. Discounts are available for packages of sessions. The investment for a 10 session package is $3000. If you choose a package, the package payment is due prior to the first session. A coupon code will be issued once the package is paid. The coupon code can be used for the number of sessions specified in the package. If an appointment is missed, canceled or rescheduled without 24 hours notice, the coupon code will be processed for that session resulting in the session being lost. The coupon code will expire 1 year after the date of package purchase resulting in a subsequent loss of any and all unused sessions in the package.

Cooperation: Clients currently under the care of a licensed health care provider will continue to follow that providers’ advice including medications and therapy. If the client doesn't continue care and it impacts the work of the sessions, this will consider it a material breach of this agreement and subsequent sessions could be forfeit.

Confidentiality: All your records are confidential, released only upon the client’s written authorization or if required by law.

Release and Waiver of Liability: By signing below, you are agreeing that you are not currently involved in any criminal or civil matters where you are seeking to enhance or develop memories for use in litigation.

Under California law, the use of hypnosis to aid memory, so-called “creation of memories” for evidence in Court may result in the evidence being excluded. You agree to defend, indemnify, and hold Cynthia Sholes harmless for claims and damages, including attorney’s fees or costs related to “creation of memories” or testimony that may arise or be related to the sessions under this contract. You assume the risk of physical injuries occurring at Cynthia Sholes’ office.

This agreement is to be governed by the laws of the state of California, excluding its’ conflict of laws provisions. If any part of this agreement may be found to be unenforceable this shall not void the entire agreement.

Informed Consent:

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Cynthia Sholes and Mind Wave Institute from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

By clicking the box, I confirm that I have read, understood, and agree to the terms of this Informed Consent Statement and Contract.

The foregoing information I have entered is true and correct to the best of my knowledge.