New Client Smoking

Address

Age
Gender

Male Female
How did you hear about us?

Friend Website Doctor
Have you been hypnotized before?
If yes, what was your experience?
How long have you been smoking?
Any previous attempts to quit smoking?

Yes No
How many cigarettes do you have a day?
Why do you want to quit smoking?
On a scale from 1-10 how important is it for you to stop smoking now?
We find it useful to sometimes use a holistic approach (mind-body-spirit) Would you consider yourself a spiritual person?

Yes No Maybe
Medical History
Are you currently undergoing medical or psychological treatment for the above issue?

Yes No
if yes, please give Doctors name and brief summary.
Any appointment changes need to be made two business days in advance. Appointments canceled without the 24 hour notice will be charged for the session.

Hypnosis is a powerful state but I can not guarantee any results. What I can do is give you my fullest attention and effort.

Please sign below indicating you understand these policies. If you are bringing a minor under 18 years old, parent or guardian signature is reguired. Thank you.
Signature
Should be Empty:

Main Line Hypnosis