I the undersigned, acknowledge that I understand and agree to the following:

I agree to pay you, Ted A. Moreno, C.Ht. a fee of $637 for a smoking cessation program. I also agree to pay you,
in full, for your services, at the time of the first session.

* I agree to give you 24-hours notice on all cancellations or changes of scheduled appointments. I understand that missing a scheduled appointment, without prior cancellation, or canceling with less than 24-hours notice may result in the loss of that prepaid session or a charge at the full current rate for sessions not prepaid.

I understand that the smoking cessation program offered by you will include the following:
* One half hour phone interview for the purpose of a customized cessation program.
* Four hypnotherapy sessions, including a 1 ½ to 2 hour “quit session”.
* Four hypnosis recordings for reinforcement of in-office therapy.
* A discount on subsequent (not prepaid) sessions that are for the purpose of smoking cessation reinforcement. **

I understand and agree to the following: that the major purpose of this program is for Vocational or Avocational Self-improvement and those problems of a psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professional Code 2908).

I also understand that success in hypnotherapy depends in a large part on my motivation, desire to accomplish my goals, diligence in listening to recordings and following the Preparing to Quit outline given to me exactly.

I understand that the only guarantee is that if I am not a non-smoker for one week by the fourth session, I can come for another session at no extra charge. No other guarantee is made as to the results or progress to be made and that there is no refund, partial or full, of any payment I make. I understand that you will, to the best of your ability, endeavor to accomplish the objective of my program/sessions.

* Additional Conditions: Regular per session fee is $167.00

** $125 for smoking cessation reinforcement sessions after first four (price good for 1 years)

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authorize this contract.

By electronically signing this document, you agree to the terms established above.

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