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 Number: ___________________________________________
Email Address: ___________________________________________
2. Purpose of This Consent
This form allows you to choose whether Change in Entropy Hypnotherapy may communicate with you by text message (SMS) and email for routine administrative and care-related matters, and separately for any optional marketing or promotional messages.
Please read each section carefully and initial only the options you want.
3. Important Information About Email and Text Messaging
Email and text messaging can be convenient, but they also involve privacy and security risks. Messages may be delayed, intercepted, misdirected, viewed by others who access your phone, email account, or device, or stored by your service provider.
If you request or permit email or text communications, you acknowledge and accept these risks to the extent permitted by law.
These methods are not for emergencies.
Do not use email or text message for urgent medical, mental health, or safety concerns. If you are in immediate danger or need emergency help, call 911. If you are in emotional distress or crisis, call or text 988.
4. Routine Administrative and Care-Related Communications
These communications may include:
appointment reminders
scheduling or rescheduling messages
intake or paperwork reminders
billing or payment reminders
requests to contact the office
limited care coordination or follow-up messages
notices about office closures or scheduling changes
Please initial your choices below:
SMS for routine administrative and care-related communications
_____ YES, I consent to receive routine administrative and care-related text messages at the phone number listed above.
_____ NO, I do not consent to receive routine administrative and care-related text messages.
Email for routine administrative and care-related communications
_____ YES, I consent to receive routine administrative and care-related emails at the email address listed above.
_____ NO, I do not consent to receive routine administrative and care-related emails.
5. Marketing and Promotional Communications
Marketing or promotional communications may include:
newsletters
announcements about new services, programs, workshops, or events
educational updates not directly related to your current care
general promotions or offers
You are not required to consent to marketing or promotional messages in order to receive services.
Please initial your choices below:
SMS marketing / promotional messages
_____ YES, I consent to receive promotional or marketing text messages from Change in Entropy Hypnotherapy at the phone number listed above.
_____ NO, I do not consent to receive promotional or marketing text messages.
Email marketing / promotional messages
_____ YES, I consent to receive promotional or marketing emails from Change in Entropy Hypnotherapy at the email address listed above.
_____ NO, I do not consent to receive promotional or marketing emails.
6. Message and Data Rates
Standard message and data rates from your wireless or internet provider may apply to text messages or emails accessed on a mobile device. You are responsible for any such charges.
7. Frequency of Messages
Message frequency will vary depending on your appointments, communications preferences, and any programs or updates you choose to receive.
8. Alternative Communication Methods
If you do not want email or text messages, or if you want to limit the type of messages you receive, alternative communication methods may include:
phone call
voicemail
postal mail
secure portal or secure form, if available
Preferred communication method: _____________________________
Preferred phone number: ___________________________________
Preferred email address: ___________________________________
9. Revoking or Changing Your Consent
You may change or revoke this consent at any time.
To stop text messages, you may:
reply STOP to a text message where available
notify the practice in writing
call the office at (907) 278-1180
email [email protected]
To unsubscribe from marketing emails, you may use the unsubscribe method included in the email where applicable, or contact the practice directly.
Revocation of consent will not affect communications already sent before your request was processed.
10. Limits on Email and Text Use
The practice may choose not to use email or text for certain subjects, including:
emergencies
highly sensitive or extensive clinical discussions
complex treatment issues better handled in session or by phone
matters requiring secure documents or formal signatures
The practice may instead ask you to schedule an appointment, use a secure method, or communicate by phone.
11. Client Acknowledgment
By signing below, I acknowledge that:
I have read and understand this SMS and Email Communication Consent.
I understand the risks of email and text communications, including privacy and security risks.
I understand that email and text are not appropriate for emergencies.
I understand that I may refuse, limit, or revoke consent at any time.
I understand that I am not required to agree to marketing communications in order to receive services.
12. Signature
Client Name: ____________________________________________
Client Signature: _________________________________________
Date: ___________________________________________________
13. Personal Representative, if Applicable
Name of Personal Representative: ____________________________
Relationship to Client: ____________________________________
Authority to Act for Client: _________________________________
Signature of Personal Representative: ________________________
Date: ___________________________________________________
14. Practice Use Only
Processed By: ___________________________________________
Date Entered: ___________________________________________
Notes / Restrictions: ______________________________________