Confidentiality Agreement

I am committed to protecting your privacy and preserving your trust.

Below is the Hypno Haven Confidentiality Agreement. You will be sent a copy to sign prior to our first session.

Please contact me if you have any questions.

 In compliance with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations, Birka Burnison (“Birka”) respects Client’s privacy and holds in confidence information acquired during the professional service.

Hypnotherapy sessions will only be recorded if Client submits a written request specifying the date of the hypnotherapy session Client wishes to be recorded.

By signing the Client’s initials, Client authorizes Birka to communicate information such as appointment reminders, MP3 recordings of sessions (recorded only per Client’s request), and other information pertaining to Client’s hypnotherapy sessions via the specified communications:

☐ Email:____________________________________________   initials: _________________

☐ Phone (*including voicemails & texts):_____________________________  initials: ____________

☐ Phone (*answered calls only):_____________________________  initials: ____________

☐ Whats App (*including voicemails & texts):_____________________________  initials: _________

Information obtained from Client is never shared with any other persons, verbally, digitally or in hardcopy form, unless Client has authorized Birka to share specified information to the designated provider/person(s) and Client has signed a Release of Information form. Client has a right to expect that information revealed in sessions not be disclosed without extraordinary justification. The conditions that justify the release of information and by law must be reported to the appropriate agencies, are the following:

  1. Information is required by a Court mandate or issued subpoena.

  2. Any suspected child abuse, dependent adult abuse, or elder abuse.

  3. If Client poses a threat of imminent danger to another person.

  4. If Client poses a serious risk of suicide and is an imminent danger to self.

  5. Report to law enforcement authorities knowledge of a felony that has been, or is being committed.