Inner Deep Dive

Disclosures Form

I use email address to uniquely identify you and protect your privacy.

Disclosure: California SB-577

The following disclosure fulfills the requirements of the California Senate Bill #SB577, passed in September 2002, affecting all non-licensed helping professionals offering alternative health care. The undersigned Client acknowledges that he or she has been informed of the following information: Hypnotherapist agrees to provide professional services in accordance with acquired training and experience giving undivided attention during scheduled consultations to facilitate Client's benefits. 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 feeling 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 of achieving 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. Accordingly, Hypnotherapists are not issued licenses by any state governmental agency to engage in their professional services.

I, Eromi Guneratne, have acquired the following education, training, experience, and qualifications to perform the services offered to my Clients: Certified Clinical Hypnotherapist with American Council of Hypnotist Examiners (ACHE #125-006). Trained and certified through the two oldest licensed hypnotherapy schools in the United States: Hypnotherapy Training Institute (HTI) and HCH Institute. Completed six month supervised internship with HCH Institute.

For complaints not resolved by Hypnotherapist, contact the American Council of Hypnotist Examiners, 3435 Camino del Rio S. Ste. 316, San Diego, CA 92108 I, the undersigned Client, acknowledge that I have been advised of the foregoing information, and that I have been given a copy of this "Client Information" form.

Acknowledge SB577

Disclosure: Telehealth

I understand that Telehealth is a mode of delivering health care services, including hypnotherapy, via communication technologies (e.g. Internet or phone) to facilitate consultation, sessions, education, and self-management of a client's care.

By signing this form, I understand and agree to the following:

1. Online hypnotherapy sessions will be conducted over video teleconferencing software (such as Zoom or equivalent).

2. I am responsible for providing my side of the required audio/video hardware (i.e. computer or phone) and reliable internet connection.

3. I am responsible for using a location that is comfortable, private, and free from distractions or intrusions.

4. Enabling video provides my hypnotherapist with critical non-verbal cues that greatly improve the quality of my session.

5. I have a right to confidentiality with regard to my sessions and related communications.

6. I understand that hypnotherapy via telehealth has been shown to be effective in treating a wide range of issues but that results cannot be guaranteed or assured.

7. I understand that some systems support video or audio recordings, and that neither I nor my therapist may record the sessions without the other party’s permission.

I, the undersigned Client, acknowledge that I have read, understood, and agree to the information provided above. I have the right to ask for and receive to my satisfaction any further clarification to the use of online teleconference software for remote hypnotherapy sessions.

Acknowledge Teleconference

Disclosure: Session recording

Audio/Video: I generally do not record audio or video from our sessions, and never without your explicit approval. Any recordings you authorize would be for my own personal review to optimize your specific care and/or my general practice. Any recordings would be stored privately and deleted in a timely fashion unless explicitly authorized by you. You may change your approval at any time or for any particular session. Text Transcripts: I may record a session's text transcription until I finish writing my post-session notes which I use to plan and guide subsequent or future sessions. Please check boxes for any types of recording you'd like to avoid without asking you first:

Never record video

Never record audio

Client's Signature:

Please type your full name below then press Accept to digitally sign this form.

Version: 20250216