MOTTERN INSTITUTE - for MIND-BODY WELLNESS
Client Forms
 
Forms you will find on this page:
 
  • Hypnosis Consultation Agreement
  • Hypnosis Intake Form
  • Client Bill of Rights
 
Hypnosis Consultation Agreement
 
Hypnosis is a guided experience that helps you access your subconscious mind and make changes that you think will be beneficial to you.  You will never do or say anything in hypnosis that you do not choose to do or say.  You may end the experience at any time you wish.  There are no harmful side effects of hypnosis and no danger to you. No one can make you do anything that you don’t choose to do.
Please note, however, that your health and well-being depend on your choices and how you choose to care for yourself physically, emotionally, mentally and spiritually.  This includes your choices to seek informed medical advice from qualified physicians.
 
The Five Agreements
The following agreements shall always guide our experience and conduct together.
1.      We will not hit each other.
2.      We will not have sex with each other.
3.      We will not break things around each other.
4.      We will not use alcohol or other drugs while we are working with each other.
5.      We agree not to run away from each other.
 
Basic Premises
This experience is guided by the following premises. As human beings, all we do is behave.  Almost all of our behavior is chosen behavior.  The chosen behavior is composed of four parts- thinking, doing, emotions and physiology (physical feelings).  We always have direct control over our thinking and doing.  We have indirect control over our emotions and physiology.  Everything we do in this life is an attempt to meet the five basic genetic needs of survival, love, control, fun and independence. 
 
Our needs are met best through our relationships with the important people in our lives.  The following habits either move us closer to those we care about (caring habits) or move us away from those we care about (deadly habits):
   
7 Caring Habits: Supporting, Encouraging, Listening, Accepting, Trusting, Respecting, Negotiating Differences
 
7 Deadly Habits: Criticizing, Blaming, Complaining, Nagging, Threatening, Punishing, Bribing, Rewarding to Control
 
 By undertaking this hypnosis experience, I agree to fully engage in the process, work toward my stated goals and attempt to use only caring habits in my relationships with others.  If I have any reservations about this process and cannot sign in good conscience, I agree to discuss them before proceeding further. 
 
The information gained through this experience may be used for research purposes but your name will be withheld and you will be assigned a pseudonym.
By signing this agreement, I hereby release Ron Mottern and Mottern Institute for Mind-Body Wellness from any and all liability.
 
Print Client Name:
 
Client Signature:
 
Date:
Disclaimer
“The services I render are held out to the public as nontherapeutic hypnotism, defined as the use of hypnosis to inculcate positive thinking and the capacity for self-hypnosis. I do not represent my services as any form of health care or psychotherapy, and despite research to the contrary, by law I may make no health benefit claims for my services."
 
Hypnosis Intake Form
 
General Information
 
Name:
Address:
City:                                                              State:                                      Zip:
Sex:                 Age:                Height:                        Weight:            
Marital Status:                        Spouse's Name:                                               
Phone Number (please include area code):
Email address:
Your Occupation (or Former Occupation):
Highest level of education completed (e.g., 8 grade, high school, GED, 2 years college, etc.): 
Have you ever been treated for emotional problems?  (Please circle one.)    Yes            No
If yes, please explain:
Have you ever had seizures?  (Please circle one.)   Yes     No
 
Specific Information
 
  • Do you easily become engrossed in shows that you are watching or books you are reading?    (Please circle one.)   Yes     No
  • Do you play a musical instrument?  (Please circle one.)   Yes     No
  • Do you like to daydream?  (Please circle one.)   Yes     No
  • When you travel on a trip (even to work or to the market), do you find yourself arriving at your destination and not remembering the specifics of the trip?  (Please circle one.)   Yes     No
  • Can you roll your eyes in the back of your head?  (Please circle one.)   Yes     No
  • Have you ever been in love?  (Please circle one.)   Yes     No
  • Do you dream in color?   (Please circle one)     Yes     No
  • Have you ever been hypnotized before? (Please circle one.)            Yes            No
 
If you have been hypnotized, what were the circumstances which led you to undertake hypnosis (addictions, weight loss, smoking, etc): 
What were the results of the hypnosis?
If the hypnosis failed to produce the desired results, what do you think was the reason for this? 
What do you want from this experience (lessening of cravings/urges, stress reduction, break addiction cycle, etc.)?
What are you doing to get you closer to what you want?
What could you be doing but aren't that would get you closer to what you want?
What are you willing to do to help you achieve your goal? 
What are you not willing to do to help you achieve your goal?
Please indicate on the scale below where you think you are in relation to achieving your goal at this time:0     1          2          3         4          5         6          7          8         9         10
  0=no progress     5=moderate progress     10=exceptional progress  
       
Preparation
 
If you were planning to take your perfect vacation, where would that be (beach, mountains, etc)? 
Please tell me what you would be doing on your perfect vacation that would make it fantastic. 
 
Client Bill of Rights
 
Contact Information:
Dr. Ron Mottern
PO Box 733
Liberty Hill, TX 78642
512-913-0168
ron.mottern@gmail.com
 
Education and Certifications:
  • PhD in Educational Psychology & Research, University of Tennessee, Knoxville, TN
  • MA in Human Services, St. Edward’s University, Austin TX
  • BA in English, Sam Houston State University, Huntsville, TX
 
  • Certified Hypnotist (CH), National Guild of Hypnotists, Merrimack, NH
  • Certified in Clinical Hypnosis (CCH), American School of Clinical Hypnosis, International, Oak Ridge, TN
  • Certified in Hypnosis for Pain Management (CHPM), Healthy Visions Wellness Center, Clinton, TN
  • Reality Therapy Certified (RTC), William Glasser Institute, Chatsworth, CA
 
Notice:
AS THE STATE OF TEXAS 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 state governments.
  • I am not a physician nor 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 a 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.
  • Consulting Hypnotists help ordinary, everyday people with ordinary, everyday problems using individual hypnotic techniques.
 
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 services or behavior that I cannot personally resolve for you, you may contact the National Guild of Hypnotists at P.O. Box 308, Merrimack, NH 03054-0308, (603) 429-9438, to seek redress. Services other than my own may be available to you in the community. You may locate such providers in the telephone book.
 
Fees:
  • Payment is due at the time of the session.
  • We accept cash, credit cards and payments through PayPal and Square.
  • We do not accept insurance.
  • Payments are non-refundable.
 
Insurance:
I suggest you think of my services as something that you will pay for personally. That will both protect your privacy and help you place greater value on the work you are doing. In general, insurance companies do not like to cover hypnotic services, and I caution you not to expect them to do so.
 
Length of Services:
Although many clients receive benefits from one session, additional sessions generally increase the efficacy and duration of the benefits. Clients are initially scheduled for four (4) sessions but may continue with follow-up sessions on a periodic basis, as required. 
 
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 about you.
 
My Approach:
I was trained in hypnosis by Ron Eslinger, RN, CRNA, MA, APN, BCH, CMI, FNCH, Captain (USN Retired) at Healthy Visions Wellness Center in Oak Ridge, TN, using the certification course materials for the National Guild of Hypnotists as well as his own course materials for certification in clinical hypnosis with the American School of Clinical Hypnosis, International.  I combine these teachings with my own training and education and continue to study and research effective uses and methods of hypnosis. 
 
Client Signature:
I have received and read this Client Bill of Rights and understand what I have read.
 
Print Client Name:
 
Client Signature:
 
Date:
 
 
Mens sana in corpore sano - A sound mind in a sound body
Website Builder provided by  Vistaprint