Change in Entropy Hypnotherapy
Website: https://www.change-in-entropy.com/
Effective Date: March 17, 2026
Last Updated: March 17, 2026
Practice Contact Information
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180
1. Client Information
Client Full Name: ________________________________________
Date of Birth: ____________________________________________
Phone: _________________________________________________
Email: _________________________________________________
2. Purpose of This Release
I understand that Change in Entropy Hypnotherapy would like my permission to use certain information, statements, images, audio, or video for educational, informational, promotional, marketing, or business purposes.
I understand that by agreeing to this release, I may allow Change in Entropy Hypnotherapy to use my testimonial, comments, likeness, image, voice, or other identifying information in the ways I approve below.
I understand that use of a testimonial or media may indicate or suggest that I have received services from Change in Entropy Hypnotherapy.
3. What I Authorize
I authorize Change in Entropy Hypnotherapy to use the following. Initial each item you approve:
_____ Written testimonial or review provided by me
_____ Edited version of my written testimonial for length, grammar, or clarity, without changing overall meaning
_____ First name only
_____ First name and last initial
_____ Full name
_____ Anonymous testimonial with no name used
_____ Photograph(s) of me
_____ Video recording(s) of me
_____ Audio recording(s) of me
_____ My voice only
_____ My likeness, image, and appearance
_____ Statements I make in an interview or recorded session created for testimonial purposes
4. Approved Uses
I authorize Change in Entropy Hypnotherapy to use the approved testimonial and/or media in the following places. Initial each item you approve:
_____ Website
_____ Blog or educational content
_____ Social media accounts
_____ Printed marketing materials
_____ Brochures or handouts
_____ Email newsletters
_____ Online advertisements
_____ Workshop or presentation materials
_____ Other: _______________________________________________
5. Testimonial Text or Description of Media
If applicable, the testimonial, quote, or description of media covered by this release is:
If no text is written above, this release applies to the testimonial, statement, image, audio, or video that I separately provide or approve.
6. Identification Preference
Please choose one:
☐ I want my testimonial or media used anonymously.
☐ I allow my first name only to be used.
☐ I allow my first name and last initial to be used.
☐ I allow my full name to be used.
☐ I allow my image or likeness to be used.
☐ I do not allow my image or likeness to be used.
7. Editing and Use
I understand that Change in Entropy Hypnotherapy may format, crop, resize, edit for grammar, clarity, length, audio quality, or visual presentation, and combine approved materials with other content, so long as the overall meaning of my testimonial is not materially changed.
Initial one:
_____ YES, I allow reasonable editing as described above.
_____ NO, I do not allow editing beyond basic formatting.
8. Review Before Publication
Initial one:
_____ YES, I want to review and approve the final version before public use.
_____ NO, I do not need to review the final version before public use.
If review is requested, Change in Entropy Hypnotherapy will make reasonable efforts to provide a review opportunity before first publication, but is not required to use the material if approval is delayed or not received.
9. Compensation
Initial one:
_____ I understand that I will not receive compensation for the approved use of my testimonial or media unless separately agreed in writing.
_____ I will receive compensation as follows: _______________________
10. Voluntary Authorization
I understand that signing this release is voluntary.
I understand that I am not required to sign this form in order to receive services from Change in Entropy Hypnotherapy.
I understand that refusing to sign this form will not affect my access to services.
11. Privacy and Public Disclosure Acknowledgment
I understand that if my testimonial, quote, photo, video, or audio is used publicly:
it may reveal or suggest that I received services from Change in Entropy Hypnotherapy
members of the public may view, copy, share, repost, comment on, or redistribute the material
once material is published or shared publicly, complete removal or recall may not be possible
information disclosed publicly may no longer remain private
12. Duration and Revocation
This authorization will remain in effect until:
☐ Revoked by me in writing
☐ Specific date: ___________________________________________
☐ Specific event: ___________________________________________
I understand that I may revoke this authorization at any time by giving written notice to Change in Entropy Hypnotherapy at [email protected] or the mailing address listed above.
I understand that revocation will apply to future use after the request is received and processed, but may not apply to materials already printed, published, posted, distributed, or otherwise used before revocation.
13. Client Acknowledgment
By signing below, I acknowledge that:
I have read and understand this Testimonials / Media Release.
I understand that allowing use of a testimonial or media may identify me as a client or former client of Change in Entropy Hypnotherapy.
I understand the possible privacy implications of public use.
I understand that signing is voluntary.
I understand I may revoke this authorization in writing for future uses, subject to the limits described above.
I authorize Change in Entropy Hypnotherapy to use only the items and uses I approved in this form.
14. Signature
Client Name: ____________________________________________
Client Signature: _________________________________________
Date: ___________________________________________________
15. Personal Representative, If Applicable
Name of Personal Representative: ____________________________
Relationship to Client: ____________________________________
Authority to Act for Client: _________________________________
Signature of Personal Representative: ________________________
Date: ___________________________________________________
16. Practice Use Only
Material Received On: _____________________________________
Approved For Use On: _____________________________________
Reviewed By: ____________________________________________
Restrictions / Notes: ______________________________________