Indigo Dragon Center • 451 La Veta Ave, Encinitas, CA 92024 • Personal Cell: 858 922 8339
ALL INFORMATION IS STRICTLY CONFIDENTIAL
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Parents/Siblings/Children in physical or in Spirit*
About the hypnotic state and the potential for positive outcomes:
Within our being there lies the potential to elevate, heal, and inspire ourselves as well as others. Hypnosis is considered a significant tool to actualize this process. By delving into the roots of human conditioning and habit formation, we may work with the non-tangible aspects of human behavior. By utilizing effective methods, we begin to diminish subtle underlying beliefs, negative thinking patterns and habits to accomplish positive behavioral changes. The sense of “returning home, to peace, to one’s true connection with the Divine, Universe, God, other…” From within this experienced feeling, one is supported to align with one’s natural eagerness toward positive and healthy habits, inspirations, actions, accomplishments and outcomes.
The practice of hypnosis encompasses the “induction” of a hypnotic state, or expanded state of consciousness, by applying individualized techniques to induce a relaxed, more aware and connected state. Wishing the hypnotic state, you will be fully awake and capable of responding verbally and authentically, at all times. Very few people fall completely asleep during hypnosis, but it does occur.
Through hypnosis, there is the potential to change the belief systems with which our behaviors and habits have been conditioned. Hypnosis is a state of altered consciousness induced by verbal suggestion, visualization and/or other forms of stimuli to the senses. It is a state in which the subconscious mind enjoys a heightened level of susceptibility for the potential of to further pre-determined “post-hypnotic suggestions” by bypassing the conscious mind through suggestion, relaxation, and imagery.
Please share about yourself so I may support you:
Lingering & Present Stressors. Please rate by number (1 being low stress to 10 being high stress) the areas in your life where you feel emotional stress at this time.
Aspirations for the future. Please rate by number (1 being low stress to 10 being high stress) the areas in your life where you feel emotional stress at this time.
What is the reason for seeking hypnotherapy and what would you like to focus on?
Please list possible benefits you’re hoping to gain from your hypnotherapy experiences:
How did you come hear of my services?
Have you participated in a hypnotherapy session before? Y N
If yes, how was your previous experience(s)?
The Presence of Love: Within my hypnotherapy sessions, I utilize words such as the Divine, Pure Love, the Infinite and others. Are you comfortable with these words? Y N
Please share your preference for how you refer to a higher power, if you do:
Your imagined sacred safe place in nature: Within a hypnotherapy session, we are often given the opportunity to imagine a beautiful tranquil place, in nature, where you feel safe, fully supported and where possibilities are infinite. This place can be real or purely within your imagination. Share with me, in what environment would you feel fully supported, safe and at peace?
Your wonderful imagination: If you were gifted free-time, to do anything you could imagine in the following 3 scenarios of expression, what would you love to do?
Share the activity, environment and how it makes you feel.
Distinction of character you respect and admire: When you first image a person you respect, be it someone you know, have studied or imagine, what qualities do they embody?
Personal Practices:: Please share your present practice of self-care, self-love, meditation, prayer, exercise, movement, eating, journaling, creativity, spend time in nature, other.
Looking back so you may move forward: We’ve all experienced varying degrees of trauma, change or confusion in your life. By listing those that stand out below, it will support the healing and reframing process within hypnotherapy session. We will go into further detail during our sessions. Hypnotherapy is a safe state of mind to become aware of elevated ways of being with these memories.
Medical History:
Note: Hypnotherapy is not traditional therapy. The following questions support me in navigating your session within my code of ethics and my commitment to serve you.
Have you been given a diagnosis for psychological treatment? Y N
Are you currently taking prescription medications? Y N
Feel free to wear comfortable and nurturing clothing to your sessions. Bringing a favorite blanket and pillow to your session is encouraged and welcomed.
For Zoom sessions, please do create a comfortable setting for yourself with a pillow for under your head and one for beneath your knees. Adjust the lighting in the room to enhance your relaxed state and silence all notifications on devices. Important: Please do have your laptop or tablet connected to your charger or fully charged and placed so that I may see your face easily.
Contact lens wearers: during hypnosis, your eyes could be closed for up to least 45 minutes. If your contacts will cause eye irritation, please remember to bring a lens holder/ solution to remove them.
Do you require extra sensitivity to your hearing? Y N
If yes, please inform me so I may position myself for your optimal hearing.
Sharon Belknap’s Education & Training:
I am formally trained and certified by the Hypnotherapy Training Institute and studied under Randal Churchill. I am a Member of the American Council of Hypnotist Examiners and participate in ongoing continued education. • ACHE Certification #HT 122-023
Fees:
Welcome new client intake - 30-minutes questions & answers via FaceTime or Zoom is a gift from me to establish your desired outcomes and goals.
Hypnotherapy Sessions
60 minutes - $160 • 45 minutes - $130
Packages • (Three) 60-minute Sessions $450 • (Six) 60-Minute Sessions $850
All fees are paid in advance of sessions.
Sharon Belknap
@Sharon-Belknap
I accept payments through Venmo @Sharon-Belknap. Cash and checks are always appreciated. Sessions can be done both in-person and virtually via Zoom.
Cash, Venmo or Credit cards are accepted at time of session.
Scheduling your New Client Intake or Hypnotherapy Sessions:
1. Your can text or call me at (858) 922-8339 to schedule your appointment
2. Sunday afternoon appointments Visit www.indigodragoncenter.com
3. Weekday appointments visit www.lifeflowhypnotherapy.com
Cancellation Policy: Your appointment time is reserved exclusively for you. Please arrive promptly to obtain your full session. If you must cancel or reschedule, I require a 48-hour prior notice. If you must reschedule due to an emergency, please notify me as soon as possible. If you need to cancel your session, your pre-paid funds transfer to your next scheduled session.
Confidentiality: All hypnosis sessions are confidential. I will not release any information to anyone without written authorization from you, except as provided by law.
Services: Hypnosis is a natural and safe, self-help process. Hypnosis is not a practice of medicine or psychotherapy. Sharon Belknap is not a licensed therapist. The hypnosis services provided are for educational and self-improvement purposes and are not intended for the diagnosis or treatment of any medical or psychological condition. If you have an on-going medical illness, mental disability, or mental illness, please consult a medical doctor, psychiatrist or psychologist licensed by the state of in which you reside. I do not present my services as any form of health care and despite research to the contrary, by law, I may make no health benefit or claims for services. During hypnosis sessions, clients are completely aware of their surroundings and suggestions, however persons are so relaxed that they intently focus on the voice of the hypnotist. The ability to visualize or imagine is enhanced. Most clients comment that they were truly relaxed and have not been so relaxed in quite some time. Hypnosis is safe and pleasurable.Please note that hypnosis may take several sessions to achieve. Some clients achieve an expanded state of consciousness easily the very first time, while with others, it may take a few sessions and some practice.
Ethical standards: I offer hypnosis services in accordance with the Code of Ethics and Standards prescribed by the American Council of Hypnotist Examiners. It is your right to refuse any aspect of my services and to seek services of another certified hypnotist at any time.
Client Consent and Release: : I understand that my success is contingent on my commitment to improving my life and circumstances. I have been advised that I am free to terminate any or all sessions at any time and I have agreed to participate in each session to the best of my ability. I understand that Sharon Belknap, CHt, is not diagnosing, prescribing for, nor treating any physical or mental ailments and I do not hold her responsible for them. I understand that the sessions may produce emotional and physical responses that may be unexpected and of a highly personal nature. These sessions are not a substitute for any medical or psychiatric consultations. I agree to inform Sharon Belknap, CHt, of all physical or mental conditions which may affect our work together. I understand that our sessions may respectfully involve Reiki, healing touch, and I give the practitioner permission and consent to do so in order to help me establish a beneficial state of hypnosis. I understand that the practitioner is a facilitator of hypnosis and is not practicing any other profession that requires a license under the laws of the State of California. I authorize that this release form applies to all future appointments as well. I also authorize that I am of legal age and in consideration of my acceptance as a participant in hypnosis or group session, or any other Sharon Belknap, CHt, session, I for myself, my heirs, executors, administrators and assignees, do hereby release and discharge Sharon Belknap, CHt, from all claims of damages, copyright, demands or actions whatsoever in any manner arising from my participation. Further, I understand that audio recordings are made during sessions and that Sharon Belknap, CHt, retains the copyright of these recordings.
I declare that I have read this consent and release and that I fully understand and agree to the terms described. I acknowledge receipt of a copy of this statement.
The undersigned Client acknowledges that they, he, she, have been informed of the following information:
Client Name:
Sharon Belknap, CHt, (hereafter referred to as “hypnotherapist”) agrees to provide professional services in accordance with acquired training and experience giving undivided attention during scheduled consultations to facilitate Client’s benefits.
PLEASE INITIAL EACH OF THE FOLLOWING:
Hypnotherapist’s work is Client-centered.
Services provided utilize induction of hypnosis, and methods and principles used to help clients discover their inner creative abilities to develop positive thinking and feelings and to transform undesirable habits and behavior patterns.
Therapeutic goals are to achieve freedom from restrictive thought and belief systems, to assist in solving personal problems, developing motivation and achieving goals. Client may be taught the use of self-hypnotic techniques to assist in achieving goals and resolving issues that have been mutually agreed upon by Client and Hypnotherapist.
Hypnosis is not a state of sleep, but is a natural state of mind that can produce extraordinary levels of relaxation of mind, body and emotions.
The principles and theories upon which hypnotherapy is based are accessing and utilizing the power of one’s inner resources. Hypnosis can transcend the critical, analytical level of mind, and facilitate the acceptance of suggestions, directions and instructions desired by the Client. The therapeutic use of Hypnosis can also elicit information and insights from the inner mind. The hypnotherapist utilizes interviews, discussion and hypnotic methods dealing with underlying issues whenever appropriate, with the goal to achieve effective and lasting results.
Services to be provided do not include the practice of medicine, as Hypnotherapist is not a licensed physician. These services are non-diagnostic, and are complementary to the healing arts services that are licensed by the state. The California State Legislature has determined that state licensing may not be conferred upon an occupational group for purposes of status or prestige. The primary purpose of licensing laws for legally defined Healing Arts and Mental Health professionals is to protect public health and safety. The Legislature finds that these non-medical complementary and alternative services do not pose a known risk to the health and safety of California residents, and that restricting access to those services due to technical violations of the Medical Practice Act is not warranted. Accordingly, Hypnotherapists are not issued licenses by any State Governmental Agency to engage in their professional services.
I understand that these sessions are not psychotherapy but are a therapeutic alternative aimed at creating positive changes in my life. I agree to inform my hypnotherapist of all physical or mental conditions that might affect her work with me.
I understand that I am a full committed partner in the creating changes I aspire to embody. I am committed to participate authentically during my sessions and to eagerly engage in fostering my realizations to expand the positive impact created in our sessions.
I, Sharon Belknap, CHt, have acquired the following education, training, experience, and qualifications to perform the services offered to my Clients:
Client Signature (if under 18, must be signed by a legal guardian)
