DRUG-FREE PAIN MANAGEMENT AND ANXIETY AGREEMENT

This agreement supersedes any verbal discussions and sets out the conditions and understandings for using medical hypnosis for pain and/or anxiety management between Emile A. Allen, m.D. ( hereinafter referred to as "Dr. Allen", Dr. Emile Allen") and the undersigned patient/parent/legal guardian (hereinafter referred to as "you", “the Client").

 

By filling out the box with your name and email at the end of this document and submitting it via the MindWiseProtocol.com website, you are agreeing to the terms set therein.

 

  • EMILE A. ALLEN, M.D. IS A RETIRED PHYSICIAN AND SURGEON. DR. ALLEN IS ONLY ACTING AS A CONSULTING HYPNOTIST TO TEACH YOU (THE CLIENT) SELF-HYPNOSIS SO YOU CAN BETTER MANAGE YOUR PAIN AND/OR ANXIETY. DR. ALLEN IS NOT ACTIVELY PRACTICING MEDICINE AND IS NOT, AND WILL NOT, TREAT YOUR MEDICAL CONDITION IN ANY MANNER WHAT-SO-EVER. ANY COMMENTS AND/OR SUGGESTIONS FROM DR. ALLEN ARE NOT TO BE CONSTRUED AS MEDICAL ADVICE OR TREATMENT AND SHOULD BE DISCUSSED WITH YOUR (THE CLIENT'S) TREATING PHYSICIAN(S) / HEALTHCARE PROVIDER(S). IT IS YOUR FULL RESPONSIBILITY TO SEEK AND/OR CONTINUE MEDICAL CARE WITH A LICENSED HEALTHCARE PROVIDER IN YOUR STATE OF RESIDENCE.

 

  • All sessions are performed via video conferencing. The Client will need access to high-speed internet, a quiet environment, and a computer, tablet, or smart phone.

 

  • The Client agrees and is willing to be guided, via video conferencing, through the self-hypnosis processes and techniques, including guided visual imagery, relaxation, and stress reduction.

 

  • Due to the multi-factorial nature of the Client’s life events, there are no guarantees of results or the number of sessions required for Pain and/or Anxiety Management.

 

  • The Client agrees that issues or matters not communicated may not be resolved or might impede the successful achievement of the Client’s goals and objectives for Pain and/or Anxiety Management.

 

  • The Client agrees to Dr. Allen's fee schedule for a Block of Sessions. Each session is up to 45 minutes in length. A 15-minute, complementary Drug-Free Pain Management Consultation is available to discuss the effectiveness of hypnosis in Pain and Anxiety Management. For Clients who want to start immediately the consultation will be integrated into the first Pain Management Session. The number of sessions depends on the client’s life history and willingness to follow instructions and recommendations. In general, 3 to 5 Sessions are recommended to establish and teach a customized, personal strategy for Pain and/or Anxiety Management for each client. Sessions 1 and 2 are back-to-back, one day apart. Any remaining sessions can be spread out over a few days, weeks, or months depending upon the client’s goals and life conditions.

Services / Fees:

  • Complementary Drug-Free Pain Management Consultation: 15 minutes

  • 1 Session: $150 (up to 45-minutes)

  • 3 Pack: $300 (a total of three, 45-minute sessions)

  • 5 Pack: $500 (a total of five, 45-minute sessions)

  • This is an “At Will Agreement” and can be terminated via email by either party. A minimum of 3 sessions are necessary to determine the Client's progress. Any remaining funds beyond 3 sessions would be returned to the Client at the prorated amount if services were terminated.
     

  • The Client agrees he/she will always follow the advice of his/her treating physician(s) / healthcare provider(s).
     

  • It is the Client's sole responsibility to see a physician for an evaluation of their pain / anxiety to rule out any physical or mental illness / condition that might be causing their pain such as: migraine headaches, cancer, fibromyalgia, a pinched nerve, etc.

  • The Client should always continue to follow the medical treatment plans of their physician(s) / healthcare provider(s) prior to changing current medical or psychological therapies.
     

  • DO NOT STOP YOUR MEDICATIONS. The Client will not stop taking or reducing their medications without their physician's advice. Abruptly stopping medications or substances that the Client may or may not be dependent upon, or addicted to, could result in withdrawal symptoms that may require hospitalization or even cause injury and/or death.
     

  • If the Client has an emergency situation or experiences withdrawal symptoms from medication reduction as a part of their medical advice from their physician(s) / healthcare provider(s), the Client must call 911 or their treating physician(s) / healthcare provider(s)
     

  • Confidentiality: The Client understands that information will be held as confidential unless the Client states otherwise via a written or video graphed testimonial produced, obtained, or provided by the Client. Confidentiality does not apply if the Client reports child or elder abuse or neglect or threatens to harm them self or someone else. Such incidences would be reported to the appropriate authorities for the protection of Client or other parties. Additionally, the Client understands that the use of technology is not always secure and accepts the risks of confidentiality in the use of email, text, phone, and video conferencing.

    By typing your name and date below, you are agreeing to all of the terms and conditions of this Agreement.

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