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Forms

New clients please fill out the "Alternative Health Care Professionals Disclosure" and the "Client Intake Form" before your first session.

Client Intake Form

Birthday
Month
Day
Year
Have you ever attempted suicide?
YES
NO
Are you currently having suicidal thoughts?
YES
NO
Are you currently taking medication?
YES
NO
Do you use alcohol?
YES
NO
Do you use other drugs?
YES
NO

Please Read and Check the box to acknowledge :

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Alternative Health Care Professionals Disclosure

The following disclosure is intended to fulfill the requirements of the California Senate Bill #SB577, passed in September 2002, affecting all non-licensed helping professionals offering alternative health care.


  1. Susy Nayak has a Ph.D. in Psychology and more than 1000 clinical supervised hours in Psychotherapy. Her training is extensive in Psychotherapy and this informs her work, but this is not the service offered. Susy Nayak is not licensed as a Psychologist.

  2. Clinical Hypnotherapists are not licensed physicians. They are not qualified to diagnose, treat, or prescribe for physical or mental conditions.

  3. The use of Hypnotherapy and other Energy Therapies is alternative and complementary to healing arts services licensed by the State of California.

  4. The services offered in Hypnotherapy are not licensed by the State of California but the training Susy Nayak has received in Hypnotherapy has been approved and registered by the California Bureau of Private Postsecondary and Vocational Education, the International Board of Regression Therapy, The professional Board of Hypnotherapy, the California Board of Registered Nurses and the California Board of Behavioral Science.

  5. Services offered include Hypnotherapy, and EFT (Emotional Freedom Technique), for the the purpose of pain management, goal setting, performance enhancement, self-healing, regression therapy, spiritual emergence issues, trauma, relationship issues, learning enhancement, stress management, career issuers, exploring life purpose, personal growth and discovery. None of these services is intended to be a substitute for medical or psychological care. Any issue beyond the scope of Susy Nayak’s training and practice will be referred to a licensed practitioner.

  6. It is the goal of Susy Nayak to provide clients with a safe, non-judgemental and supportive environment where clients can gain insights into established patterns of behaviors and work toward transformation and personal growth. Because all the services and modalities are based on the empowerment model, all clients do their own work and healing with guidance of a co-creative facilitator.

  7. Susy Nayak has completed the HCH Hypnotherapy School California approved training in Hypnotherapy and is a Certified Hypnotherapist. Susy Nayak is also trained in EFT. She has completed a six-month Clinical Internship training which resulted in a Clinical Hypnotherapist Certification.


I have read and understand the disclosure.



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Let's Connect

Thanks for submitting!

Email: SusyNayak@yahoo.com

Phone: 510-299-5285

© 2023 by Susan Nayak

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