First Name *

Last Name *

Sufix

Email *

Phone *

Date of birth

Address

Street Address *

City

State

Country

Postal Code

You agree to use of email correspondence?

Yes

You agree to receive a customized guided hypnosis session MP3 via email.

Yes

It is okay to leave phone messages or text you at this number?

Yes

In case of an emergency, name a close friend or relative

Emergency Contact Last Name *

Emergency Contact First Name *

Emergency Contact Phone Number *

What changes are you hoping to accomplish through life coaching/hypnotherapy? *

Are you willing to participate in the full coaching and life transformation experience, including human potential coaching, Mental and Emotional Release®, Neuro-linguistic Programming (NLP), and Integral Hypnotherapy™ which consists of self-hypnosis, guided imagery, and meditation? *

Yes

What are your three biggest personal strengths? *

Medical Information

Have you ever had any mental health treatment, such as with a counselor, therapist, or psychiatrist? *

Yes

Give a brief history of your mental health treatment and the results of your treatment:

Are you receiving any mental health or medical treatment now? *

Yes

What's the diagnosis?

Have you spoken to your medical professional about using coaching and or hypnotherapy as an adjunct to your treatment? *

Yes

N/A

Coaching Agreement

I understand that all services provided by Curtis B. McCullom are for educational and self-improvement purposes only. These services include human potential coaching, Mental and Emotional Release®, Neuro-linguistic Programming (NLP), and Integral Hypnotherapy™, which consists of self-hypnosis, guided imagery, and meditation.

I understand that hypnotherapy is an educational process that facilitates access to internal resources that assist people in increasing motivation or altering behavior patterns to create positive change. The education of hypnotherapy is classified under Human Services in the Health and Human Services Division of the Classification of Instructional Programs by the United States Department of Education. The services provided are also described in the Dictionary of Occupational Titles published by the U.S. Department of Labor; see code 079.157.010.

I understand that Curtis B. McCullom may assist clients with weight loss and/or other health and fitness goals, may provide general nutritional advice, and/or recommend published books, food guides, and health and fitness publications. This is not a substitute for medical advice, and you are advised to seek your Doctor’s approval before making any medical/health/lifestyle changes.

I further understand that Curtis B. McCullom does not practice psychotherapy or medicine. Therefore, his services are not the practice of psychotherapy or medicine and are not offered as a substitute for counseling, psychotherapy, psychiatric, or medical treatment. Consultation or referral from a licensed physician or mental health professional may be required before providing hypnotherapy services.

I agree that all complaints or disputes arising from my participation in Integral Hypnotherapy™ sessions, seminars or events, and any other activity related to the above, should they occur, shall initially be decided by the Board of Directors of the International Board of Hypnotherapy (IBH) by its published procedures for reviewing and resolving complaints against its members (published at www.internationalboardofhypnotherapy.com.) I further agree to mandatory mediation for any claims of damages or disputes before filing a suit in a court of law.

If you have a complaint about the facilitation process that Curtis B. McCullom still needs to resolve satisfactorily, please contact the International Board of Hypnotherapy at 2132 Osuna Rd. NE, Suite B, Albuquerque, NM 87113. You can refuse any aspect of his services and seek another provider’s service at any time. Curtis B. McCullom’s fee per session is up to $500.00. The sessions are 45 to 90 minutes.

I further understand that recordings may be made at any public sessions or events and that Curtis McCullom and his organization retain the copyright to all these recordings.

I am of legal age, and in consideration of my acceptance as a participant in these sessions, seminars, or workshops, I, for myself, my heirs, my executors, administrators, and assignees, do hereby release and discharge your Curtis McCullom and his organization or other participants in any of the activities, from any claims or damages arising from or growing out of my participation in said activities.

I Agree with the Coaching Agreement

I Agree

Limits of Confidentiality of Information

Our Commitment to Your Success

To be more successful in reaching my goals, I agree to the following:

1. Be an active participant in my coaching experience and see myself as a partner in the transformative nature of this process.

2. Recognize that my thoughts, feelings, images, and actions directly affect the quality of my life.

3. Acknowledge that my well-being depends on how well I care for myself physically, emotionally, intellectually, and spiritually.

4. Accept that blaming others or myself is totally futile.

5. Take responsibility for my life experience because I create my life to the best of my ability with what I know right now.

6. I agree to be on time for my sessions and allow at least 24 hours of advance notice should I need to cancel or reschedule a session (949) 504-3653. If I don’t give a 24-hour notice, I can be charged for the session.

I Agree with the Limits on Confidentiality of Information

I agree

Refund Policy – Bespoke Human Potential Coaching Memberships

At Bespoke Human Potential Coaching, we are committed to delivering a transformational coaching experience. We believe in the quality of our programs and the value they bring when fully experienced with intention and engagement.

Customary Refund Policy

Our refund policy is rooted in client satisfaction. If, after your first coaching session, you feel that the experience did not meet your expectations, we offer a 100% refund for that initial session. Simply communicate your concerns directly, and your refund will be issued immediately—no questions asked.

This policy is designed to honor your time, energy, and investment while ensuring our mutual alignment and commitment to transformation.

Month-to-Month Memberships – Three-Month Commitment

While our memberships are billed on a monthly basis, they are structured with a minimum three-month commitment to support lasting change. This is based on our philosophy that true transformation takes time, consistency, and momentum.

Early cancellations before completing the initial three months are not eligible for refunds.
After the third-month period, clients may cancel their membership at any time before the next billing cycle to avoid future charges.

We encourage all clients to approach the membership with full intention and participation. Transformation isn’t instant—it’s a process of Learning, Growing, Expanding, and Transforming™.

If you have any questions or require support, please don’t hesitate to contact our team at i[email protected].

Refund Policy Agreement Signature

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Agreement Signature

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Signature Date