Hypnotherapy Disclosure Statement
Purpose: The purpose of this Disclosure Statement is to comply with the requirements of the Washington Administrative Code (WAC), Section 246-810-031 and the Counselor Credentialing Act, Revised Code of Washington (RCW), Chapter 18.19. The purpose of the law regulating counselors (including Hypnotherapists) is to provide protection for public health and safety and to empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct.
Contact Information: My name is Ugo Tsalapatanis, founder of Pacific Hypnosis LLC. I am doing business as a registered Hypnotherapist in Kirkland,WA. I can be contacted at 425-326-0483 or at firstname.lastname@example.org.
Hypnosis Education and Training: I was first trained in 2011 at ARCHE Ericksonian Hypnosis Academy in Paris, France. I did the practitioner training in Ericksonian Hypnosis and in Neurolinguistic Programming (NLP) and then the master practitioner in Hypnosis in 2014. I also trained in 2015 in Transpersonal Hypnosis at the Institute for Therapeutic Learnings in Seatlle. I have currently well over 500 hours of training in Hypnosis, NLP and Hypnotherapy.
I am a Certified Consulting Hypnotist with the National Guild of Hypnotists. As a practicing Hypnotherapist, I am registered with the Washington State Department of Health (Credential Number HP 60576860).
As a Hypnotherapist, I may not provide a medical diagnosis, prescribe medications, or recommend discontinuance of medically prescribed treatments. Practitioners providing hypnotherapy for a fee must be registered with the Department of Health for the protection of the public health and safety. Registration of an individual with the Department does not include recognition of any practice standards, nor necessarily implies the effectiveness of any treatment. You have the right to choose a Hypnotherapist who best suits your needs and purposes; additional services other than my own are available to you in the community. You have the right to refuse hypnotherapy services at any time. As my client, you have a right to be free of physical, verbal or sexual abuse. You also have a right to know the expected duration of sessions, if known, and may assert any right without retaliation.
Redress: As a certified member of the National Guild of Hypnotists, I practice in accordance with its Code of Ethics and Standards of Conduct. If you have a complaint about my professional conduct that I cannot resolve for you personally, you may file a formal complaint with the Washington State Department of Health in accordance with the information provided in “Purpose” above.
Fees: (I do not take insurance) $260 per session. 6 Session Package: $1300 (save $260).
Sessions last about an hour.
All unused packaged sessions are refundable upon request. If you do not complete your package, you will be charge the full rate for your used packaged sessions and be reimbursed for the remaining amount.
Cancellation Policy: Cancellations made less than 24 hours before the appointment may result in a $200 fee.
Confidentiality: I will not release any personal information about the services you receive to anyone without written authorization from you, except as provided for by law. You have the right for access to my written records about you.
My Approach: Hypnosis is one of many tools that can help to restore balance and wellness in your life in several ways. Hypnotherapy has been shown to be helpful when used under medical referral as an adjunct to medical treatments that address certain physical or emotional conditions. In addition, hypnosis has been shown to be effective in helping clients enhance their personal skills and abilities, regain self-confidence, explore their spirituality, determine and set realistic goals, release apprehensions and concerns, manage situational stress in a positive manner, regain self-control, and promote increased wellness in their lives.
I have provided a copy of this Disclosure Statement to the client undersigned.
Practitioner Signature: _____________________________________Date: _______________________________
Printed Name: ____________________________________________
I have read and received a copy of this Disclosure Statement and I understand what I have read.
Client Signature: _________________________________________ Date: _______________________________
Printed Name: _______________________________________ email: ____________________________