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Client Intake Forms

Please take a moment to first read the Practitioner/Client Agreement and then fill in and submit the Client Information & Agreement. 
 

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Practitioner/Client Agreement


This is an agreement between Practitioner Noelle Romero and the client.  No client can legally be treated without reading and signing the agreement below.
Practitioner and Client hereby agree:


1. Practitioner and client will meet on a weekly basis for a one hour minimally, in person or over the phone until goal has been met. Clients will prepay the agreed rate before the session.  Cancellations must be made within twenty-four hours in advance to avoid charge.  Missed appointments, no call, and no shows are non-refundable.


2. Practitioner agrees to facilitate, and Client agrees to follow the coaching plan.  Both agree to attend all sessions prepared with required tasking.


3. Client understands that the results of any coaching will depend on their ability to take action and follow the discussed plan to the best of their abilities.  Client assumes the responsibility to take on action on all agreements which include being on time, tasking and learning the required material.  Results will depend on the client's commitment to their mental health and personal breakthrough. Client understands that the Practitioner cannot do the work for them.  


4. Practitioner Noelle Romero agrees to safeguard all information obtained during the session.  All identifying information taken during client's assessment and sessions are 100 percent confidential.  Confidentiality does not apply in cases of abuse/neglect of children or elderly. Confidentiality does not apply to cases of potential self-harm or harm to others.  Confidentiality does not apply to cases involving criminal proceedings or illegal drug use.  


5. Information: Although the client's records are physical property of Noelle Romero, client has the right to request restriction on certain uses and disclosures of your information.  Client may request and obtain a copy of their health record and session details at any time. 


6. Benefits of NLP:  One major benefit gained from participating in Neurolinguistic Programming, is the client may achieve tremendous breakthrough in their mental health and behaviors.  Some clients have even reported relief from chronic pain or illness.  Clients understands that every case is different and pain relief is not a guarantee, only a possibility.  Client agrees to go "all in" and do whatever it takes to comply to all modalities with an open mind and full commitment to success.  


7. Risks: Client will adhere and comply to all of the Practitioner's warnings when installing new values or behaviors.  Client understands that when a new habit is installed though hypnosis, it is very hard to undo or change after the fact.  Practitioner will help client weigh out the benefits of change to ensure its ecology before hypnosis.  Client is free to stop the hypnosis session at any time.  All participation and hypnosis are voluntary.  Practitioner will help client set an achievable outcome during the personal history session so both parties understand the goal.


8. Client understands that Noelle Romero is not providing any psychological or medical advice and should in no way replace treatment of a licensed health care provider.  Your Practitioner is not a licensed medical Doctor, Psychologist, Master's in Family Therapy (MFT) or a Master's in Social Work (MSW).  The services client receives are not licensed in the state, nor are they regulated by the government body.  Noelle will only provide client with the services trained which includes Master Neurolinguistic Practitioner, Practitioner of Timeline Therapy (TM) and Certification in Hypnotherapy. 


9. Referrals Program: Please share your success story with the people you love so they too can experience the profound benefits of Neurolinguistic Programming.  If referral signs up, existing client will receive either a credit or extra time during the following session. 


 

Client Information & Agreement
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If you are already under a medical doctor's care, Noelle will need a written permission from the provider.  Please upload file here.  Thank you!

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