VIDEO CONFERENCE AGREEMENT PAIN/ANXIETY MANAGEMENT 

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

 

By checking the box next to each section, you are agreeing to the terms set therein.

 

  • Emile Allen, M.D. is a retired surgeon who specialized in urology. He is no longer practicing medicine and is in not acting in any way, shape, or form as your treating physician. He is only working in the capacity as a Medical Hypnotist to teach you self-hypnosis.

 

  • 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. An introductory session to general hypnosis is available. A minimum of 3 sessions are required for Pain and/or Anxiety Management before a refund is considered. Usually no more than 10 sessions are needed.

  • Introductory to Hypnosis up to 45 mins

  • 1 Session: $150

  • 3 Sessions: $300

  • 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 physician(s).
     

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

  • Dr. Allen is not treating your medical condition; therefore, any advice or suggestions from Dr. Allen are not to be construed as medical advice or treatment and should be discussed with the Client's treating physician(s).
     

  • Dr. Allen's MindWise Protocol teaches self-hypnosis, which will become an adjunct or support to medical care by the Client's physician.
     

  • The Client should always continue to follow any present medical treatment plans and consult with their medical doctor or therapist prior to changing current medical or psychological therapies.
     

  • 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 medical treatment, the Client must call 911 or their physician.
     

  • Confidentiality: The Client understands that information will be held as confidential unless the Client states otherwise in writing, such as providing a testimonial. 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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