VRishi Immersive Hypnotherapy

Consent to Release Confidential Information

Jithendran Sellamuthu, C.MH. | AHA Cert 013165 | VRishi Hypno LLC

This consent authorizes the release and exchange of confidential information from my records (or my child’s records) between:

Hypnotherapist: Jithendran Sellamuthu, C.MH., VRishi Immersive Hypnotherapy

and the medical doctor, therapist, or agency identified below.

I understand that this authorization is valid for six (6) months from the date below. I also understand that this information will be used only for the purpose of coordinating care and will not be disclosed to any other party without my written consent.

Medical Doctor / Therapist / Agency Name

Address / Contact Information

I have read and understand the information above and agree to the terms as described.

Client Name (Please Print)

Email Address

Client Signature (draw below)

Date

October 1, 2026