Stop Smoking Questionnaire

Date of 1st Consultation

Full Name *

Phone *

Email Address *

Address *

City *

State *

Zipcode *

Date of Birth *

Gender * MaleFemale

How did you hear about us? *

What is the name of your current GP?

Do we have your permission to contact them? * YesNo

Have you ever been hypnotised?

How was that experience?

Reason you are coming in for hypnosis (what do you expect to resolve?)

How long have you had this issue?

Any previous attempt to address this issue? YES/NO Results?

Are you currently taking any medications? Medical conditions? (Seizures, epilepsy, etc.?)

Are there any particular situations or events that create a desire to smoke?

Is there anything else would like to add before we start our sessions?

Mind Coach Signature

Client Signature *

Notes
*** The Trainer is neither a medical doctor nor a psychologist and does not treat nor diagnose medical or psychological conditions. Progress reports may be sent to the attending doctor. Any persons who is currently working with a licensed professional (therapist, psychologist, MD, social worker) must get a written referral.

* Sessions may be recorded for educational purposes.

Stop Smoking

Who knows someone who is ready to take back control of their life and stop smoking forever?

Using the latest Applied Psychology, Hypnosis, Guided Visualisation Techniques and E.F.T, we provide those who are truly ready to stop smoking with the tools to stop smoking for life in a fast, effective and pain free way.

The average pack a day smoker spends approximately $180 a week or $10,000 a year on cigarette addiction.

On average the life-span of a smoker and quality of health is far less than non-smokers.

Stop Smoking

3 Sessions to complete your Stop Smoking for life package

Contact Us Now To Schedule Your Stop Smoking Hypnosis Consultation

Pages

Our Services

Contact Us