Change in Entropy Hypnotherapy
Website: https://www.change-in-entropy.com/
Effective Date: March 17, 2026
Last Updated: March 17, 2026
Business Contact Information
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180
1. Purpose of This Agreement
This Client Informed Consent and Services Agreement (“Agreement”) explains the nature of services provided by Change in Entropy Hypnotherapy, the risks and benefits of those services, client rights and responsibilities, office policies, privacy practices, and the terms under which services are provided.
By signing this Agreement, you acknowledge that you have read it, understand it, have had the opportunity to ask questions, and voluntarily agree to participate in services subject to these terms.
2. Nature of Services
Change in Entropy Hypnotherapy may provide services such as:
hypnotherapy
guided relaxation
stress reduction support
habit and behavior-change support
mindset and performance support
wellness-focused sessions and related education
Services are intended to support personal wellness and client goals. Services are not emergency care.
Unless separately stated in writing, services are not a substitute for:
medical diagnosis or treatment
psychiatric care
psychological testing
crisis intervention
emergency mental health services
You understand that hypnotherapy is a collaborative process and that results vary from person to person. No specific outcome, cure, or guarantee of success is promised.
3. Voluntary Participation
Your participation is voluntary. You may ask questions at any time and may choose to stop or pause a session at any time.
You understand that hypnosis is generally a state of focused attention and relaxation and that you remain responsible for your choices, actions, and participation throughout the process.
4. Potential Benefits
Possible benefits may include, depending on your goals and circumstances:
increased relaxation
improved focus
stress reduction
support for habit change
improved confidence or motivation
support with performance, mindset, or emotional regulation
Benefits are not guaranteed.
5. Possible Risks and Limitations
You understand that participating in hypnotherapy or related services may involve risks or limitations, including:
temporary emotional discomfort
unexpected memories, feelings, or reactions
fatigue, dizziness, or grogginess after a session
frustration if progress is slower than expected
limited benefit or no benefit
You agree to tell the practitioner about any relevant health, mental health, or safety concerns that may affect your participation.
If you have a medical, psychiatric, neurological, or other condition that could affect your safety or suitability for services, you agree to consult an appropriate licensed healthcare professional as needed.
If at any point services are determined to be inappropriate, outside scope, or no longer advisable, Change in Entropy Hypnotherapy may recommend referral, postponement, or discontinuation of services.
6. Client Responsibilities
As a client, you agree to:
provide accurate and complete information to the best of your knowledge
disclose relevant medical, mental health, and safety information
participate honestly and respectfully
follow agreed scheduling, payment, and communication policies
seek emergency or higher-level care when needed
understand that your progress depends in part on your participation and follow-through
You agree not to attend a session while impaired in a way that makes participation unsafe or ineffective.
7. Emergency and Crisis Policy
Change in Entropy Hypnotherapy does not provide emergency services, crisis response, or 24/7 availability.
Do not use the website, contact forms, email, text, voicemail, or routine scheduling channels for urgent or emergency situations.
If you are experiencing a medical emergency, mental health crisis, thoughts of self-harm, thoughts of harming others, or any urgent safety concern, call 911, go to the nearest emergency room, or contact an appropriate crisis service immediately.
8. Communications and Response Times
You may communicate with the practice using the contact information listed above for scheduling, administrative questions, and routine matters.
Electronic communications, including email and text messages, may not always be fully secure. By choosing to communicate electronically, you acknowledge and accept those risks to the extent permitted by law.
Unless otherwise agreed in writing:
routine communications are handled during normal business hours
messages are answered as reasonably available
electronic communications are not for emergencies
You may request a preferred method of communication, and reasonable requests will be honored when feasible.
9. Confidentiality and Privacy
Your information will be handled in accordance with applicable privacy laws and the practice’s Privacy Policy and, where applicable, Notice of Privacy Practices.
In general, information shared in sessions is treated as private and confidential, except where disclosure is permitted or required by law, including situations such as:
risk of serious harm to yourself or another person
suspected abuse, neglect, or exploitation where reporting is required
court orders, subpoenas, or other lawful legal process
health oversight, licensing, or compliance requirements
treatment, payment, or operational purposes as allowed by law
other circumstances required or permitted by applicable law
Where applicable, separately maintained psychotherapy notes receive heightened legal protection. HIPAA generally requires authorization for most disclosures of psychotherapy notes.
10. Records
The practice may maintain records relating to services provided, scheduling, payment, communications, treatment planning, progress, and other business or service-related matters.
You may have rights to request access to or amendment of certain records, subject to legal limitations.
Any request for records, letters, summaries, forms, or third-party disclosures may require written authorization and may involve processing time or fees where permitted by law.
11. Releases of Information
Except as otherwise permitted or required by law, the practice will not release your information to third parties without your written authorization.
If you want information shared with another provider, family member, employer, school, attorney, or other person, you may be asked to sign a separate authorization form.
12. Telehealth or Remote Sessions, If Offered
If services are provided by phone, video, or other remote methods, you understand that:
technology may fail or be interrupted
privacy can be affected by your environment or technology provider
you are responsible for using a private location when possible
the practitioner may end or reschedule a remote session if privacy, safety, or technical quality is insufficient
You agree to provide your current physical location at the start of a remote session if requested for safety or legal reasons.
13. Appointments, Cancellations, and No-Shows
By scheduling services, you agree to the appointment and cancellation rules of the practice.
Current policy:
Cancellation notice required: [insert number] hours
Late cancellation fee: [insert amount or percentage]
No-show fee: [insert amount or percentage]
Late arrival policy: [insert policy]
If you arrive late, the session may be shortened or rescheduled depending on availability, and the full session fee may still apply.
Repeated missed appointments, late cancellations, nonpayment, safety concerns, or other boundary issues may result in rescheduling requirements or termination of services.
14. Fees and Payment Terms
You agree to pay the fees in effect at the time services are provided.
Current fees:
Initial session: $[insert amount]
Standard session: $[insert amount]
Other service or package details: [insert details]
Payment is due: [insert when payment is due]
Accepted payment methods: [insert methods]
Any returned payment, chargeback, declined card, or unpaid balance may be subject to additional administrative handling and collection steps as permitted by law.
If the practice offers self-pay or uninsured services subject to applicable federal rules, you may be entitled to receive a Good Faith Estimate of expected charges.
15. Refund Policy
Unless otherwise stated in writing:
fees for completed sessions are nonrefundable
missed appointment fees and late cancellation fees may be nonrefundable
prepaid packages, programs, or deposits are governed by the written terms provided at purchase
Any exception is at the sole discretion of the practice unless otherwise required by law.
16. Scope of Practice and Referrals
Change in Entropy Hypnotherapy reserves the right to decline, postpone, or terminate services when appropriate, including if:
the requested service is outside scope
the client’s needs require a higher level of care
the client would be better served by another provider
the working relationship is no longer appropriate or effective
safety, legal, ethical, or payment concerns arise
Referrals may be recommended to physicians, licensed therapists, psychiatrists, emergency services, or other qualified professionals when appropriate.
17. Social Media, Testimonials, and Public Interaction
To protect privacy and professional boundaries:
clients should not expect confidential communication through public social media
public comments, reviews, follows, tags, or direct messages may affect privacy
the practice will not acknowledge a client relationship publicly without consent, except as required by law
If the practice wishes to use a testimonial, photo, video, or story for marketing or educational purposes, a separate written authorization will be obtained.
18. Minors and Personal Representatives
If services are provided to a minor or to a person represented by a parent, guardian, conservator, or other legally authorized personal representative, the signer represents that they have authority to consent.
Additional consent forms may be required depending on the circumstances and applicable law.
19. No Guarantee of Results
You understand and agree that:
no outcome is guaranteed
past results do not predict future results
participation does not guarantee symptom relief, behavior change, or achievement of any personal goal
20. Consent to Services
By signing below, you acknowledge and agree that:
you have read and understood this Agreement;
you have had the opportunity to ask questions and receive answers;
you understand the nature, potential benefits, and possible risks of services;
you understand that services are voluntary and may be stopped at any time;
you understand the privacy, communication, cancellation, and payment policies described above;
you consent to receive services from Change in Entropy Hypnotherapy under these terms.
21. Optional Consent for Email and Text Communications
Please initial one:
_____ YES I consent to receive appointment reminders, scheduling messages, and routine administrative communications by email and/or text message.
_____ NO I do not consent to routine email and/or text communications except as necessary or required by law.
Preferred contact method: ____________________________________
Preferred phone number: _____________________________________
Preferred email address: _____________________________________
22. Client Acknowledgment and Signature
Client Full Name: __________________________________________
Date of Birth: _____________________________________________
Address: _________________________________________________
Phone: _________________________________________________
Email: _________________________________________________
Client Signature: _________________________________________
Date: ___________________________________________________
23. Parent, Guardian, or Personal Representative, If Applicable
Name: _________________________________________________
Relationship to Client: ____________________________________
Authority to Sign: ________________________________________
Signature: ______________________________________________
Date: ___________________________________________________
24. Practice Representative Signature
Practice Representative: ___________________________________
Signature: ______________________________________________
Date: ___________________________________________________