Non-smokers retreat Interesting but disturbing facts about tobacco Smoking is an “Empty Habit.” An empty habit is one that once had psychological or social meaning, but no longer does. Every cigarette deprives you of four minutes of life. If you tried to drink a pure vial of nicotine, you would be dead before you finished the vial. You just die slower since the nicotine in cigarettes is filtered. One ordinary cigar may contain two lethal doses of nicotine. There have been many more warnings about the dangers of smoking than there have been ways to stop the habit. Three out of four smokers express a desire to quit, and 60% have tried unsuccessfully to stop at least once. Register for a Non-Smoker's Retreat The Effects of Smoking On The Digestive System and Liver Smoking helps cause heartburn, peptic ulcers, and liver problems. In addition, smoking changes the way food is processed. Heartburn occurs when the lining of the esophagus comes into contact with stomach juices. To prevent this from happening, there is a ring-like one-way valve at the junction where the esophagus and stomach meet. Normally, this valve allows food to go one way into the stomach without back washing. However, smoking weakens the valve allowing stomach acids to backup into the esophagus. Also, smoking transports harsh bile salts into the stomach, causing further irritation. Finally, smoking injures the esophagus directly, so it is more vulnerable to cancer-causing substances. Smoking also damages the liver, which is often called the body’s chemical factory. Its over 500 functions include blood cell repair, detoxifying poisons and alcohol, processing nutrients, and making energy available to the body. So vital is the liver that without it we die. The important point is that although the liver can take a great deal of abuse, it is vital and vulnerable. Smoking shortens its life, and without it, life is not possible. On a positive note, there is some evidence that damage to the digestive system ends when smoking is stopped. But at some point the damage becomes permanent. When you stop smoking your lungs and heart benefit. Smoking and Cholesterol Smoking actually lowers the HDL good cholesterol, the kind that reduces the risk of blood plaques in the arteries. Therefore, even if you are trying to eat right, if you still smoke you may be fighting a losing nutritional battle. Reasons People Give Regarding Why They Smoke Smoking Releases Tension and Helps Me To Relax (Calms My Nerves) Smoking Helps Me to Feel More Confident in Social Situations I Find Smoking Pleasurable (Smell, Taste, and Sight) I Smoke Because I Am Bored I Smoke Because I Need To Be Doing Something All The Time, Especially With My Hands. All My Friends Smoke Smoking Makes Me Look More Like A Mature Adult Smoking Helps Me Keep My Body Weight Under Control. Smoking Helps Me Maintain Control When I Become Angry Reasons People May Have For Smoking Which Are Outside Their Awareness Self Destructive Tendencies Peer Pressure Defiance of Parental Injunctions Not To Smoke Sexual Sublimation Visualization of the “Breath of Life” Hidden Self-Destructive Wish Wish To Feel In Control (When you are in control of your life you will not need to be in control of your death.) An Excuse For a Break From Work Tasks Benefits of Becoming a Non-Smoker You will breathe easier. Your sense of taste and smell will improve. You will have more energy. You will have more money. It is like giving yourself a raise. Your overall health risks eventually decrease. Your heart will not have to work so hard. You will have more self-confidence and a feeling of personal empowerment. Other people will not be disturbed by your smoking behavior. Your body will love being free of tobacco, which is its natural state. What is Clinical Hypnosis? Hypnosis can be defined as an altered state of awareness, consciousness, or perception. In simple terms, hypnosis is a highly relaxed state in which the client’s conscious and unconscious mind is focused and receptive to therapeutic suggestion. When Hypnosis is used for treating a defined problem or addressing a specific need, this is called clinical hypnosis. It is a special form of communication that increases motivation and the ability to control physical responses and behavior. Hypnotherapy is frequently used in conjunction with other forms of psychotherapy. Hypnotic treatment is only one tool, and when used by itself, the treatment is usually short-term. Almost everyone has experienced one form or another of hypnotic trance at some time in his or her life. Think of those times when you were driving on an expressway and caught yourself briefly unaware of what you were doing, or when you or your children were so engrossed in a TV program that you were unaware that someone else had entered the room. The unconscious mind is responsible for the ease with which we automatically tie a shoelace, button a shirt, or sign our name. There is nothing to fear, because hypnosis is a safe procedure when used professionally. The relaxation you will experience will be pleasant and refreshing. In a state of heightened suggestibility, such as hypnosis, we focus attention on new ideas, new learning, and new experiences that are imprinted in the unconscious and become automatic responses. Trance is a natural process, however everyone is unique and therefore people often experience hypnosis differently. There is no right or wrong way to experience trance. Schedule and Format for the Non-Smoker's Retreat The Non-Smokers Retreat is a Research-Based Program and lasts for three (3) consecutive hours. This program was designed and developed by Dr. William R. Boyd, Jr. and includes a non-smoking break at the end of each hour. The cost is $350 and is NOT covered by insurance, so payment will be made out of pocket, paid by either cash or personal check. The retreat can be arranged and scheduled for an individual, a couple, or a group of up to six (6) people. First Hour Get to know you, your smoking history, and your hypnosis background Review your reasons for participating in the Non-Smokers Retreat Participate in an exercise demonstrating your unconscious mind Brief review of the User’s Guide Book Smoking Facts History of Hypnosis Hypnosis Education Myths about Hypnosis Learning Self-Hypnosis Second Hour DVD Presentation on the Effects of Smoking on Nutrition Absorption Interesting, but disturbing facts about tobacco and nicotine Self-Test to become a Non-Smoker Exercises from the Users’ Guide Self-Understanding regarding your motivation to stop smoking Illustration of a Habit Strengthen Your Motivation to become a non-smoker permanently Instruction about how to Use Self-Hypnosis Third Hour - Hypnosis Session Post Hypnosis Session Review Follow-Up Program – Introduction to and Instruction on Successful Completion Concluding Ritual – Leaving the Retreat as a Non-Smoker Each Participant Will Receive Users Guide (Program Workbook) CD to Practice Self-Hypnosis Follow-Up Program A Certificate of Accomplishment when the follow-up program is completed *Booster Hypnosis sessions are also available if needed for follow-up Non-smokers retreat REGISTRATION FORM Step 1 of 3 33% Today's Date* MM slash DD slash YYYY Your name* First Name Middle Name Last Name Date of Birth* MM slash DD slash YYYY Social Security #* Home Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Employer* Home PhoneWork PhoneCell PhoneEmail Address Method of Payment Cash Check How Many Years Have You used Tobacco?*Types of Tobacco Used* Cigarettes Cigars Snuff Why Do You Want to Quit?*Who Else in Your Home Smokes?*Have You ever Used Hypnosis Before? (If Yes, Please Explain)* Do you know anyone else who would like to know about this opportunity?Name First Middle Last PhoneAddress Street Address Address Line 2 City State / ProvinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.HIPPA Notification* The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the “medical records privacy law”, HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. You may have already received similar notices such as this one from your other health care providers. As you might expect, the HIPAA law and regulations are extremely detailed and difficult to grasp if you don’t have formal legal training. My Patient Notification of Privacy Rights is my attempt to inform you of your rights in a simple yet comprehensive fashion. Please read this document as it is important you know what patient protections HIPAA affords all of us. In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship and as such, you will find I will do all I can to protect the privacy of your mental health records. If you have any questions about any of the matters discussed in this document, please do not hesitate to ask me for further clarification. By law, I am required to secure your signature indicating you have received this Patient Notification of Privacy Rights Document. Thank you for your thoughtful consideration of these matters. I understand and have been provided a copy of Dr. Boyd’s Patient Notification of Privacy Rights Document which provides a detailed description of the potential uses and disclosures of my protected health information, as well as my rights on these matters. I understand I have the right to review this document before signing this acknowledgment form.Release of PHI I have read and fully understand the Notice of Privacy Practices for Protected Health Information (PHI) offered by Dr. Bill Boyd and Stepping Stone Retreat for Enhanced Living, LLC. In general, HIPAA privacy rules give the right to request a restriction, or release of certain restrictions regarding the use and disclosures of protected health information (PHI). An individual may also request alternate means of correspondence for confidential and protected health information. Please check all that apply below. Home Phone May leave messages with detailed information Leave message with call back number only May leave message with family member, or other person (see below) Work Phone May leave message with detailed information Leave message with call back number only Written Communication May mail to home May mail to office May fax to number below May text to number below I authorize the release of my PHI and medical information to the followingElectronic Submission* I understand that submission of this form constitutes an electronic signature authorizing the transmission of my information via email.