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NLP disclosure form from Pati McDermott

Summary: A disclosure form intended to comply with California's 2002 alternative health care law, which provides legal protection for practitioners of alternative health care.

This disclosure form is adapted from one by Tim Hallbom of the NLP Institute of California. Pati says, "I welcome feedback on any improvements anyone has to suggest."

Pati McDermott
P. O. Box 3691
Oakland, CA 94609

I, Pati McDermott, am a Certified NLP Master Practitioner, a Certified NLP Health Practitioner and a Certified Hypnotherapist. I am also an NLP teacher and consultant. I am not a California licensed mental health practitioner or physician and I do not provide psychotherapy or any other form of mental health service which would require a California state license, nor do I hold myself out to provide such services. I do not provide diagnosis or treatment of physical or mental conditions nor am I licensed by the state as a healing arts practitioner. NLP is considered a complimentary healing arts service that is not licensed by the state. For individuals or small groups I provide individualized teaching and coaching designed to help people learn how to commit to and achieve their performance goals, and remove any barriers they have to success.

Cancellation Policy

Advanced notification to change or cancel an appointment is required. Cancellations will be accepted until 10:00 PM the night before an appointment. Cancellations by email must be confirmed before that time to be accepted. Late cancellations should be made by telephone to ensure that they have been received. If you fail to give sufficient notice of a cancellation you will be charged your regular fee for that session. As a courtesy please give as much notice as possible. Tentative notice is also appreciated.

Payment Policy

Fees are due at the time that the service is provided. Payment in advance may also be made for multiple sessions. Payment plans are available by request and must be agreed to in advance.

I have read the above disclaimer and I am aware that Pati McDermottís consultations are intended to be educational and or performance coaching in nature and are not intended to be psychotherapy or any other type of licensed therapy services. ___ (Initial.)

I have read the above cancellation policy and I agree to give sufficient notice of a cancellation, as specified above, or pay my full fee for that missed appointment. ___ (Initial.)

I have read the above payment policy and I agree to pay my fees on the day of each session or in advance. ___ (Initial.)

Signature: ____________________________________________
Name (printed):________________________________________
Date:________________________________________________

Please sign and initial this agreement and return it with your check.
If you have any questions please call me.
Thank you.

Pati McDermott
877-881-4348 toll free voice mail
nlpPati@yahoo.com
www.nlpPati.com

Related articles and links

• Outline for disclosure form for NLP, coaching, or hypnosis clients, with suggestions for tailoring it to your practice.
• Our NLP and hypnosis disclosure form, also available in PDF format (20 K).
• Jason McClain's PDF coaching disclosure form includes a dispute resolution clause (56 K PDF).
• Text of California's 2002 alternative health care law.

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