Teleconsulting for Tinnitus with Kevin Hogan

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Please submit my application with the following option (choose one):

I am applying for one (1) session of Tinnitus Tele-Therapy – a private 90 minute session on the telephone with Kevin Hogan. Charge my credit card $750 upon acceptance. By checking this box and submitting this form, I am agreeing to the terms of this consultation.

OR

I am applying for a block of five (5) sessions of Tinnitus Tele-therapy. The initial session will be 90-minutes long, with subsequent sessions being 60-minutes long. Charge my credit card $2500 upon acceptance. By checking this box and submitting this form, I am agreeing to the terms of this consultation.

OR

I am applying for a block of ten (10) sessions of Tinnitus Tele-therapy. The initial session will be 90-minutes long, with subsequent sessions being 60-minutes long. Charge my credit card $4500 upon acceptance. By checking this box and submitting this form, I am agreeing to the terms of this consultation.

Terms: Session times as described above. Once your application is accepted, you will be contacted via e-mail within 1-2 days to schedule your session(s). On the day of your session(s), you will call the number you are given. Session fees are non-refundable, except as described in the terms below. A session may be re-scheduled one time per block,  no fees will be refunded for missed or delayed sessions. You will be expected to use a landline (wired) telephone, or otherwise excellent working equipment, with excellent sound quality.

Check all that apply:

Pulsatile tinnitus Severe

Pulsatile tinnitus Moderate

Whole Tone tinnitus Severe

Whole Tone tinnitus Moderate

Other sounds Severe

Other sounds Moderate

Hyperacusis Severe

Hyperacusis Moderate

Current Hearing: (Type One) Perfect, Near Perfect, Good, Fair, Poor, Deaf One Ear, Deaf Both Ears

Have Cochlear Implant

Suffering from:

Depression Severe

Depression Moderate

Anxiety Severe

Anxiety Moderate

Panic Attacks Frequent

Panic Attacks Irregular

Complex Personal Issues like divorce or recent death of loved one? Y/N:

How long have you had tinnitus? Describe.

What was the circumstance of the onset of your tinnitus?

Had you ever experienced tinnitus prior to onset? Y/N:

We Accept All Major Credit Cards

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If the Billing Address on your credit card statement is different from the one you gave above, please type it below.

Please answer thoroughly:

Why have you contacted me instead of one of the thousands of other people who might be able to be helpful for you?

I understand that the local time for a teleconsult with Kevin Hogan could begin at almost any hour of the day or night. I understand that Kevin Hogan is not a Medical Doctor and cannot prescribe medication. I give my permission for Kevin Hogan to consult with my Medical Doctor on his own time if he feels it necessary. I give Kevin Hogan permission to consult with my Professional Licensed Therapist if he feels it necessary.

I understand that Kevin Hogan has not taken clients for several years now and at any moment may decide to cease taking clients and stop working with current clients. If this occurs, a prorated refund of session fees will be made. I understand that if Kevin Hogan determines he can’t help me that a prorated refund of future session fees will be made. I will not ask Kevin Hogan to break any laws in an effort to help me improve.

I have read the above and check this box as my understanding the above information. Initials:

I do not hold Kevin Hogan responsible or liable in any way for actions I take in treating my tinnitus or results from consulting with him. I have the capacity, desire and interest to make my own decisions and will consider Kevin Hogan’s strategy as options. Initials:

I understand Kevin Hogan will never recommend herbs, vitamins,or remedies. Initials:

I understand Kevin Hogan does not accept medical insurance but if we enter into a session block that he will, at my request, fill out insurance paperwork for possible reimbursement, after the fact. Initials:

I will not ask Kevin Hogan to contact my insurance company, Medical Doctor or any other therapist. Initials:

I understand Kevin Hogan no longer regularly practices therapy and therefore am working around his business schedule. Initials:

I understand Kevin Hogan makes no promises, guarantees that my tinnitus will remit 100%. Initials:

I understand that getting well from tinnitus takes time. Initials:

I understand Kevin does not ever take phone calls from clients, except at the scheduled time. Initials:

Please enter any special considerations about you that you want Kevin to know about. Kevin receives thousands of requests per year and can only agree to help a very small percentage of those inquiring.

Your application will be reviewed within 3 days.

Your credit card will not be charged until you have been accepted. Once accepted you will be given an available time slot, at the earliest possible convenience.

You will be contacted by e-mail regarding the acceptance of your application. Kevin Hogan retains the right to turn down any application for any reason. No charges will be made to your credit card until acceptance is complete.