Jithendran Sellamuthu, C.MH. · Certified Master Hypnotist · Sessions held remotely via Zoom, where permitted by applicable law.
Client name: Date of birth:
I am the parent or legal guardian of the minor named above. I have received and read the Client Disclosure & Informed Consent, and I understand that the services are guided hypnotic techniques for self-improvement — not medical, psychological, psychiatric, or dental diagnosis or treatment — and that no specific outcome is promised or guaranteed.
I consent to the minor receiving these services. I understand that I may be present during sessions, that I will remain available during every remote session, and that I may withdraw this consent and end services at any time.
Session notes are kept confidential and are not released without written authorization, except where disclosure is required by law. Remote sessions are not recorded without written consent.
I have read and understood this consent and the accompanying disclosure. I consent to the minor named above participating in the services described.