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Disclosure Form

For purposes of this document The Practitioner refer to Barbora Smith Varclova Cth

Please read these terms and conditions which apply to the provision of my professional services. By making an appointment and submitting Client Intake Form, you are agreeing to the following terms and conditions described in Disclosure Form. If you are unable or unwilling to agree to these terms and conditions, then you should not book an appointment or continue with your course of therapy.

Privacy Statement

What data do are kept and why are needed

Name and date of birth – this are basic information that helps The Practitioner get to know client.

Address, email address, phone number – The Practitioner use this as a way of contacting client regarding sessions. The Practitioner will mainly use the method client first contact but if cannot reach client, will try a different method.

Medical professional’s details – If The Practitioner was worried that client was at risk then may need to contact client's medical professional. The Practitioner will let client know when/if going to do this.

Session notes – The Practitioner keep brief notes of session(s) in NHS approved counselling management system.

Audio recordings - Recording is made during session and copy is releases to client. Copy of recording is store in NHS approved counselling management system and deleted after 1 month after session.

Will I share your data and if I do, who will I share it with and for what purpose?

It is very unlikely that The Practitioner will share client's data. The Practitioner will not sell it on or use it for unethical reasons. The Practitioner may release information to a specific individual or agency if it has been determined that a vulnerable person (child or adult) is at risk; if a client is in imminent danger to themself or others; or if a subpoena of records has been requested. The Practitioner may also discuss your case during supervision, but I only use client's first name.

How will I store your data?

Immediately after the work is finished, The Practitioner transfer the data to NHS approved counselling management system and all physical notes are incinerated. Client's phone number(s) may be kept in The Practitioner's business mobile phone with client's first name and last initial. Only The Practitioner will access client's information.

How long will I store your data for and how will I dispose of it?

The Practitioner will keep client's details and session notes for the time required by The Practitioner's insurer (currently 7). After this time, The Practitioner will destroy any document with personal information. The Practitioner will delete client's phone number out of mobile phone after 6 months from last session. The Practitioner will re-enter client's phone number to business phone on next contact of The Practitioner.


By submitting Client Intake Form client agree to all disclaimer statements.


The Client release The Practitioner from any liability or claims that could be made against (him/her) concerning client's mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out and submitting Client Intake form. This liability waiver is not intended to exclude or restrict liability for death or personal injury caused by negligence.

Scope of Practice

Client understands that The Practitioner is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnotherapy should not be considered a replacement for the advice and/or services of a psychiatrist, psychologist, psychotherapist, or doctor.


Client gives The Practitioner full permission to hypnotize client and to use Rapid Transformational Therapy® knowing that by participating fully in the process and by listening to client's personalized recording for 21 days, client play an important role in overall success of therapy.


Client understands that although Rapid Transformational Therapy® has an incredibly high success rate, The Practitioner cannot and does not guarantee results since client's own personal success depends on many factors that The Practitioner has no control over, including client's willingness and desire to effect the changes inside themself.

Audio Recording(s)

Client gives The Practitioner full permission to make audio recordings that may include client's voice. Client understands that if a recording (or recordings) is made during or after my session(s) The Practitioner retains full copyright over any forms of media that may be produced and distributed to me.

Deepening Process

If session is person, Client hereby grants permission to The Practitioner to respectfully lift client's arm, touch client's shoulder, or rock client's head during my Rapid Transformational Therapy® session(s) in order to help facilitate the deepening process.

Client Terms and Conditions

Payments, booking and cancellation conditions

Free Discovery Call
Client may be offered a free 20 minute online initial consultation. No therapy will be provided during the consultation.

The purpose of this initial consultation is to understand client's expectations from therapy and answer client's questions. During these calls, estimates of the number of sessions required to deal with client's presenting issue are given on the basis of the information presented at that time. Estimates are only rough guidelines and are subject to change.

Booking, Payment, Cancellation, Rescheduling & Refunds 

Session is paid in full in advance via online payment (BACS, Paypal, Card payment). Session fee has to be paid 48 hours before session (after Discovery Call), fail on payment results in cancellation of session. Session cancelled less then 24 hrs will not be refunded or rescheduled exempt of extreme circumstances. Session cancelled will be rescheduled in following 3 weeks. Sessions cancelled 14 days before date can be refunded on request.

Session fees are for The Practitioner time and professional expertise and are not a guarantee of a successful outcome. Therefore, no refunds will be given for any sessions where you have attended and paid for the session.

Where a discount package or therapy program has been booked and paid for in advance, if client chooses to discontinue your therapy process before attending all the sessions, a pro rata refund will be issued after deduction of the full standard session fee for any sessions client have attended.
Session Fees

All professional fees will be disclosed to client prior to booking. The Practitioner professional fees are subject to review and may increase from time to time. Client will always receive confirmation of the professional fees before booking.

Contact between sessions
Any contact between sessions will be by telephone, WhatsApp, email or letter during office hours only 7:00-21:00 BST. Any messages received outside of these hours will be dealt with during office hours only.

Medical or psychological conditions
The Practitioner may ask questions about client's medical history to establish any contra-indications to treatment. This will also help to assess whether client's health is affecting (or being affected by) the therapeutic goals client wishes to achieve. Client is responsible to update The Practitioner of any medical changes during course of therapy, or if client is returning to therapy after a period of absence.

If client is receiving care or treatment from any medical, healthcare or therapy practitioner, e.g. GP, Psychologist, Psychiatrist or Counsellor, client may be asked to seek their permission before any therapy sessions can commence.

Please note that The Practitioner will be unable to offer my professional services if you suffer from epilepsy or any form of psychosis.

Age restriction
Client must be at least 18 years (16 years if resident of Scotland) old to participate in sessions. Clients under the age of 16 years old must have consent from a parent or guardian and will be seen in-person or online with specific consent of a parent or guardian. 

Attending session
Client is responsible to ensure that is available at session start time. If client is running late, please let The Practitioner know as soon as possible. The Practitioner will do their best to make a full session available, however, as the ability to do this will depend on bookings after your session, this cannot be guaranteed.

Hypnotherapy recordings
Hypnotherapy recordings should not be listened to whilst driving, operating machinery or undertaking any other activity where concentration is required. Any recording provided is for client's personal use only and must not be shared, lent, copied or sold under any circumstances.

Standards of behaviour
During the course of any therapy sessions, The Practitioner will treat client with respect and not abuse the trust client place in The Practitioner. The Practitioner will use best practice at all times in our mutual interest. In return, client undertake not to harm themselves, or any other person, including The Practitioner, or any property belonging to either The Practitioner or any other person.

Client agrees not to attend sessions under the influence of alcohol or recreational drugs, except those medications which have been prescribed by your doctor. If client does attend any sessions under the influence of alcohol or recreational drugs, or demonstrate violent or abusive behaviour, The Practitioner will cancel the session and may refuse to see client for any further sessions without refunding any payment already made.

Liability & Indemnity
Under no circumstances will The Practitioner be liable for any damages, including without limitation, direct, indirect, incidental, special, punitive, consequential, or other damages (including without limitation lost profits, lost revenues, or similar economic loss), whether in contract, tort, or otherwise, arising out of the advice or information provided to client during professional services provided by The Practitioner. In addition, client agree to defend, indemnify, and hold The Practitioner harmless from and against any and all claims, losses, liabilities, damages and expenses (including legal fees) arising out of client's participation in the professional services.

Governing Laws
These terms and conditions and any other matters arising out of or in relation to these terms, shall be governed by and construed in accordance with the laws of Scotland, United Kingdom. Client agrees to submit to the exclusive jurisdiction of the Scottish courts to settle any dispute which may arise out of or in connection with these terms and conditions.

Terms and Conditions Updates
These terms and conditions are subject to revisions without notice. Client is responsible to familiarise themselves with any amendments if re-started therapy with The Practitioner after a long period of absence.

Concerns & Complaints
If client have a concern or complaint regarding therapy, please discuss this with The Practitioner in the first instance and The Practitioner will endeavour to resolve the issue.

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