New Smoking Client Registration 3-Part Form

STOP SMOKING QUESTIONNAIRE

Ron Niederkofler, CHt
ron@directpathhypnosis.com
360-773-1873
FAX 360-953-8650
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Birthdate*
E-mail*
Occupation*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship to Emergency Contact*
Have you ever had a hypnosis session before?*

YesNo
Was it a positive experience? If previous answer was "no" answer N/A.*
How long have you been a smoker?*
How many cigarettes do you smoke per day?*
Have you ever tried to stop before? How did that go?*
What triggers you to reach for a cigarette?*
What are your 3 favorite cigarettes of the day?*

On a scale of 1 – 10, 10 being totally willing, what is YOUR willingness to STOP smoking?*

	1	2	3	4	5	6	7	8	9	10

1 is Not willing, 10 is Totally willing

Please list five of the benefits you expect to gain as a result of becoming a non-smoker.
Benefit 1:*
Benefit 2:*
Benefit 3:*
Benefit 4:*
Benefit 5:*
Now, go back through the above five reasons and list the one that is most important to you.*
Without thinking about it, please finish this sentence: "I don't want to stop smoking because..."*
Now, close your eyes and spend a few moments pondering your life after becoming a healthy and happy non smoker.
I will become a non smoker on (date of first session)*

MonthDayYear
Date
Signed

Clear

Client Bill of Rights and Disclosure Information

Education and Training: Ron Niederkofler received his basic training from Northwest Hypnosis Institute, with advanced training from Banyan Hypnosis Center. Ron has been a Certified Member of the National Guild of Hypnotists since 2010 and completes annual continuing education to maintain his training at a high level. The National Guild of Hypnotists is the oldest and largest hypnosis organization in the world and its certification is the most widely recognized credential for the professional practice of the hypnotic arts.

Notice: Ron is licensed in the State of Washington as a Hypnotherapist. Ron is neither a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. The client has a right to coordinated transfer of services to another practitioner. A client has a right to refuse hypnotism services at any time. A client has a right to be free of physical, verbal or sexual abuse. A client has a right to know the expected duration of sessions, and may assert any right without retaliation.

Redress: Ron is a certified member of the National Guild of Hypnotists, and practice in accordance with its Code of Ethics and Standards. If a client has a complaint about his services or behavior that cannot be resolved personally, they may contact the National Guild of Hypnotists at P.O. Box 308, Merrimack, NH 03054-0308 or call 603-429-9438 to seek redress. They can also contact the WA State Dept. of Health at P.O. Box 47869, Olympia, WA 98504-7869 or call 360-236-4700.

Fees: Each individual session is $145.00 typically lasting 60-90 minutes. Program pricing TBD at initial consultation. Program costs are non-refundable and must be used within six months of the date of purchase. Client must be aware that failure to complete the sessions as scheduled may reduce the overall effectiveness of the plan and may even void said plan. Clients must make any changes (e.g. rescheduling or canceling their appointment) at least one full business day before their appointment or they will be charged for the missed appointment. Payment in full is expected on the day of the appointment and prior to the session to enhance the benefits of hypnosis. A 10-day notice of any change in fees will be given. Generally insurance companies do not cover hypnosis and as a result, we do not process insurance claims at this time.

Confidentiality: We will not release any information to anyone without a written authorization from a client, except as provided for by law. A client has a right to be allowed access to Ron's written record about them.

My Approach: Ron's therapeutic orientation is client-centered and primarily utilizes clinical hypnosis, guided imagery, and Emotional Freedom Technique (EFT). It is non-diagnostic and non-psychological. It is not intended to replace medical or psychological therapies and services, but may be used in conjunction with them. The primary objective is self-improvement. The client is actively involved in the process and ultimately responsible for the number of sessions and the changes they wish to make. We do not guarantee or promise any specific outcomes. Hypnosis involves focusing awareness or attention internally. In this state of focused attention the individual is highly responsive to suggestion. Hypnosis can bring up negative feelings, emotions and memories. It is important for the client to always communicate with the hypnotherapist (Ron) any questions or concerns they have.

Contact Information: Ron Niederkofler
Vancouver, WA. Phone # (360) 773-1873
I have read the Bill of Rights,
understand them
and agree to these terms.
Initial*