Client Intake Form and Disclosure Notice
Thank you for reading the information on this page. By completing and submitting the Intake Form, you acknowledge having read and agreed to my stated terms.
DISCLOSURE STATEMENT AND CONSENT FORM
Credentials for Kelley T. Woods, CHt.
• Washington State Department of Health Registration No: HP10001246
• Certified Clinical Hypnotherapist since 2003
• Board Member of the International Certification Board of Clinical Hypnosis
• Certified Hypnosis Instructor with ICBCH
Session and Billing Information:
Session Length: Session duration varies from 60 to 90 mins. except for Smoking/Tobacco
Cessation, which may be up to 2 hours in length.
Fees Structure:
Individual Sessions: $200.00
Smoking Cessation: $250.00
Payment is due at the time of each session. All other financial arrangements must be agreed upon
at the time the appointment is set. As your appointment is reserved in advance, you understand that
a 48-hr cancellation notice is required and you agree to assume responsibility for full payment of
any cancelled appointment within a 48-hr notice.
You understand that confidentiality regarding your sessions will be honored between Kelley T. Woods
and yourself. This same confidentiality is respected when working with minors under the age of 18.
(Washington State law does require a hypnotherapist report any knowledge of child abuse or
intent to commit a serious criminal offense; and, if judicially requested, cannot withhold client
information if it relates directly to a serious crime.)
You grant full consent to receiving hypnosis/hypnotherapy sessions with Kelley T. Woods. You
understand that results vary, and that the above-named practitioner may not guarantee results.
The services provided utilize induction of hypnosis, methods and principles for helping clients
discover inner creative abilities, develop positive thinking and feeling, and to transform
undesired habits and behavior patterns. Therapeutic goals may include the achievement of freedom
from restrictive thought and belief systems, personal problem resolution and the development
of motivation toward defined goals.
Hypnosis is not a state of sleep but is a natural state of mind that can produce extraordinary
levels of relaxation and enhancement of mind, body and emotions. The principles and theories
upon which hypnotherapy is based include accessing and utilizing the power of one’s inner
resources. Hypnosis can transcend the critical, analytical level of mind and facilitate the
acceptance of positive suggestions, directions and instructions dictated by the client. The
therapeutic use of hypnosis can also elicit information and insights from the inner mind.
Services to be provided do not include the practice of medicine, as a hypnotherapist is not a
licensed medical professional. These services are non-diagnostic and are complementary to the
healing arts services that are licensed by the State of Washington.