Robert W. Perin, C.Ht. - dba Hypnotechs P.O. Box 1426 15315 1st Ave NE, STE 205A Duvall, WA 98019 206-785-8196 Registered Hypnotherapist - Washington #HP60794159 Education, Training and Experience: Initial hypnosis training - Western Washington University School of Psychology - September 1983 Diploma in Hypnotherapy – HMI College of Hypnotherapy #101415 Certified Hypnotherapist - National Guild of Hypnotists #59068 Certified Practitioner of Neuro-Linguistic Programming - AHA/ABNLP #161260 Additional Certifications - American Hypnosis Association & others Types of counseling provided: Kappasinian and Ericksonian Hypnotherapy Type and duration of counseling (if known): General Hypnotherapy for __________ sessions (estimated) -or- Unknown/As Needed Fee information: Cost per session: $_______ (pay as you go). Cost per ________ sessions: $_______ (in advance). Payment is due at time of service. We accept cash (exact change), checks and all major cards via Square. Charges will appear as "Hypnotechs." At least 24hr notice of cancellation is required, or the full fee will apply. Note: Clients are not liable for any fees or charges for services rendered prior to receipt of this disclosure statement. Limits of confidentiality under RCW 18.19.180 Note: Hypnotechs may video or audio record client sessions for reference use. These recordings will be treated as confidential client notes as described by RCW 18.19.180. <RCW 18.19.180 Attachment Provided> ______________ Client/Guardian initial to acknowledge. WAC 246-810-031(j) Disclosure: As a hypnotherapist, I am not credentialed to diagnose mental disorders or to conduct psychotherapy as defined in WAC 246-810-010. I understand that Hypnotechs recommends that I inform my medical doctor or mental health professional of my intent to undergo hypnosis and that written proof of this act may be required by Hypnotechs. I further understand that in the event of any conflict arising between the use of hypnosis and the instructions of my medical doctor or mental health professional, I must immediately inform my hypnotherapist of the conflict. The instructions of a medical doctor or mental health professional must always override those of my hypnotherapist, up to and including the discontinuation of the use of hypnosis. ______________ Client/Guardian initial to acknowledge.

For some types of hypnotherapy, you may be asked to allow Hypnotechs to contact your medical doctor, mental health professional, personal trainer, nutritionist, dietician or other provider to coordinate services. This request will be made in writing and will list specifically who is covered by the agreement. You may decline this request or revoke it, in writing, at any time. WAC 246-810-031(k) Disclosure: (i) Counselors practicing counseling for a fee must be credentialed with the department of health for the protection of the public health and safety. (ii) Credentialing of an individual with the department of health does not include a recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. (iii) The purpose of the Counselor Credentialing Act, chapter 18.19 RCW, is to: (A) Provide protection for public health and safety; and (B) Empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. (iv) Clients have the right to choose counselors who best suit their needs and purposes. WAC 246-810-031(l) Acts of Unprofessional Conduct Disclosure: <WAC 246-810-031(l) Attachment Provided> ______________ Client/Guardian initial to acknowledge. To file a complaint: Washington State Department of Health Health Systems Quality Assurance Complaint Intake P.O. Box 47857 Olympia, WA 98504-7857 360-236-4700 I have been given a copy of this disclosure document, and I have read and understand the information.

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Client Signature

______________________________________ Client Printed Name

______________________________________

Date

______________________________________

Hypnotherapist Signature

_____________Robert W. Perin____________ Hypnotherapist Printed Name

______________________________________

Date

If client is a minor this section must be completed by a parent or legal guardian. I have read and understand the above information.

______________________________________ _____________________________________ Guardian Signature Date ______________________________________ Guardian Printed Name

Registered Hypnotherapist

The committee welcomes the public to attend

these meetings. Contact the Department of

Health for meeting information, or refer to the

hypnotherapy profession website.

The Health Systems Quality Assurance Division

within Department of Health has information on

all health care professionals in the state. This

information includes credential status and current

restrictions or disciplinary actions, since July of

1998. If you have a question about a provider,

contact Department of Health.

Provider Credential Search Website

The link below allows you to search for any

provider by name or credential number.

https://fortress.wa.gov/doh/

providercredentialsearch/SearchCriteria.aspx

If for any reason you are unable to

resolve such a concern with your

hypnotherapist, you may choose to file a

complaint with the Department of

Health. Contact the Customer Service

Center for assistance:

Washington State Department of

Health

Mission: To protect and improve the

health of people in Washington state.

The Department of Health regulates

registered hypnotherapists within RCW

18.19 and WAC 246-810. The intent of

the laws and rules is to protect the public

and ensure the competence of those

providing hypnotherapy services.

Registered Hypnotherapists act

according to state law, department of

health rules, and national laws and

regulations.

An advisory committee, made up of two

certified counselors, two registered

hypnotherapists, and three public

members, meets quarterly to provide

advice to Department of Health.

Customer Service Center Phone:

(360) 236-4700

Fax: (360) 236-4818

Website: www.doh.wa.gov/hsqa

Email: hsqa.csc@doh.wa.gov

Address: 111 Israel Road SE

Tumwater, WA 98501

Registered Hypnotherapists Website

The link below is the Department of Health’s website

which contains specific information about the

hypnotherapy profession in the state of Washington.

http://www.doh.wa.gov/

LicensesPermitsandCertificates/

ProfessionsNewReneworUpdate/Hypnotherapist

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127. (TTY/TDD 1-800-833-6388)

DOH 670-185 June 2015

The goal of this brochure is to provide the public with general information regarding the Registered Hypnotherapist credential in Washington State.

This information is also provided to assist you in determining the type of services and provider that may best meet your needs.

What You might expect From a

Registered Hypnotherapist

Your registered hypnotherapist is encouraged to

provide you with a disclosure statement that contains

the following information:

Name and business contact information

Washington State credential number

Areas of expertise or therapeutic orientation

They should:

Inform you of the costs of your treatment, billing

practices, and how your records are maintained.

Give you the opportunity to discuss matters of

confidentiality, privacy, and release of

information.

Assist you in referrals to other professionals, if

necessary or requested.

Treat you with respect and dignity.

Remember: Your involvement in developing goals,

requesting a change in approach to services, or in

decisions about termination of services is encouraged.

Registered Hypnotherapists provide assistance

dealing with issues related but not limited to:

Smoking cessation

Weight Loss

Weight Management

Stress Reduction

Motivation

Healthy Relationships

Confidence Building

To be a Registered Hypnotherapist, your provider

must...

Complete and submit an application to the

Department of Health

Pay applicable fees

Pass a background check

Complete Four hours of training in HIV/AIDS

education.

Confidentiality and Health Care Information

Access and Disclosure

Your hypnotherapist will maintain client records.

These records are sensitive and confidential. They

should be properly documented, stored, retained, and

released only under specific circumstances. Your

hypnotherapist should have a clear procedure to

ensure confidentiality of your records.

You have the right to expect that anything you tell

your hypnotherapist will be held in confidence with a

few specific exceptions:

If you are involved in a civil or criminal lawsuit, a judge can order your file be turned over to the court;

If you make statements that a child, elderly, or disabled person has been abused or neglected, law requires your hypnotherapist to report that information to the appropriate authorities.

If you make statements that indicate you intend to harm yourself or others, your hypnotherapist may report that information to the appropriate authorities.

There also may be circumstances your

hypnotherapist may need to consult with another of

your healthcare providers. You will be asked to sign

an authorization for release of information about your

services. You should be informed of the reason for

such disclosures and are encouraged to ask questions

about anything that is unclear to you, prior to signing

this authorization.

Maintaining a Professional Relationship

Your relationship with your hypnotherapist should be

professional in nature. Hypnotherapy may include

discussing the most private aspects of your life and

relationships. It is your hypnotherapist’s

responsibility to provide an atmosphere of trust and

respect.

Hypnotherapy often deals with difficult and

emotional issues. There may be a time when you feel

confused or troubled by something that occurs during

your session. You are encouraged to talk about this

with your hypnotherapist so you can come to a more

comfortable resolution. If you don’t feel the issue has

been resolved you may wish to get a second opinion.

You may also review the section of the law that

describes forms of unprofessional conduct covered in

RCW 18.130.180. Unprofessional conduct includes,

but is not limited to:

Misrepresentations or false advertising

Incompetence, negligence, or malpractice

Violation of any state or federal code

Willful betrayal of confidentiality

Sexual misconduct