Contoh Informed Consent Pasien Hypnotherapy

No. Register Pasien : _____/____/____/__ 

 A NA MNE S A (P R E IN DUC DU C TION TI ON )

1. BIODATA PASIEN 1 2 3 4 5 6 7 8 9 10

Nama Lengkap Nama Pangilan Tanggal Lahir Umur Agama Jenis Kelamin Pekerjaan Status Pernikahan Alamat Email Alamat Rumah

: : : : : : : : : :

11 No.Telpon/WA No.Telpon/WA : 2. RIWAYAT PENYAKIT DAHULU 1 2

Asma TBC

: :

Ya / Tidak Ya / Tidak

3 Jantung : Ya / Tidak 4 Hepatitis : Ya / Tidak 5 Lain-lain (sebutkan) : 3. RIWAYAT PENYAKIT SEKARANG 1 Tiga bulan terakhir : 2 Satu bulan terakhir : 4. KELUHAN YANG DIRASAKAN ceritakan keluhan yang dirasakan saat ini sehingga datang ke terapis untuk dibantu terapi ?  ___________________  ____________________________ __________________ ___________________ ___________________ ___________________ ___________________ ____________  ___   ___________________  ____________________________ __________________ ___________________ ___________________ ___________________ ___________________ ____________  ___   ___________________  ____________________________ __________________ ___________________ ___________________ ___________________ ___________________ ____________  ___   ___________________  ____________________________ ___________________ ___________________ ___________________ ___________________ __________________ ____________  ___   ___________________  ____________________________ __________________ ___________________ ___________________ ___________________ ___________________ ____________  ___   ___________________  ____________________________ __________________ ___________________ ___________________ ___________________ ___________________ ____________  ___   ___________________  ____________________________ __________________ ___________________ ____________________ ___________________ ___________________ ____________  __   ___________________  ____________________________ __________________ ___________________ ___________________ ___________________ ___________________ ____________  ___   ___________________  ____________________________ __________________ ___________________ ___________________ ___________________ ___________________ ____________  ___   ___________________  ____________________________ __________________ ___________________ ___________________ ____________________ ____________________ ___________ __ 5. INFORMASI HYPNOTHERAPY HYPNOTHERAPY mendapatkan informasi mengenai hypnotherapy dari mana ?  __________________  ____________________________ ___________________ ___________________ ___________________ ___________________ ___________________ ____________  ___   ___________________  ____________________________ __________________ ___________________ ___________________ ___________________ ___________________ ____________ ___

Halaman 1

SURAT PERSETUJUAN “TINDAKAN HYPNOTHERAPY”

Pada Hari ini _______________, Tanggal  ____, Bulan  ______Tahun ______. Saya s elaku Pasien

atas

Nama: ______________________________, Jenis Kelamin : ______________, Umur : ___________tahun.

dengan ini menyatakan telah mengerti semua tindakan hipnoterapi yang telah dijelaskan oleh terapis saya sesuai dengan kesepakatan kami diawal dan saya mengizinkan apabila ada bagian tubuh yang akan tersentuh dan yang boleh disentuh saat melakukan terapis bagian yang aman dan tidak melanggar kode etik terapis yaitu bagian pundak, tangan dan kaki. Dan saya sangat yakin semua kegiatan hypnotherapy ini terjadi atas permintaan saya sendiri sebagai pasien guna membantu masalah yang sedang saya hadapi tanpa ada paksaan dari pihak namapun. dan kontrol terbesar dalam terapi ini adalah diri saya sendiri ketika kapanpun saya merasakan ketidaknyamanan maka saya akan memberhentikan sesi terapi ini dengan perintah diri saya sendiri. Demikianlah surat perjanjian tindakan ini saya buat untuk sama sama melindungi diri baik diri saya sendiri maupun terapis.

Ungaran, Januari 2018

Pasien

Terapist

(..........................................)

(...............................................)

Halaman 2

LAPORAN KEGIATAN TERAPIS No. Register Pasien : _____/____/____/__ 

A. KEGIATAN PRE INDUCTION

 _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________ B. KEGIATAN INDUCTION

 _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________ C. KEGIATAN DEEPENING

 _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________

Halaman 3

D. KEGIATAN DEPT LEVEL TEST

 _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________ E.

KEGIATAN PEMBERIAN SUGESTI DAN ANCHORING

 _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________ F.

KEGIATAN TERMINASI

 _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________

Halaman 4

G. KEGIATAN POST HYPNOTIC

 _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________  _______________________________________________________________________________________

Ungaran, Januari 2018 Hypnotherapist

Nurul Jannah, M.Tr.Keb, CI IBH

Halaman 5