Your full name:

Street address:

City, State & Zip code (Or Province and Country):

E-mail address:

Age:      Gender: 

Marital status:

Children?  How many?

Home Phone:

Business Phone (optional):

Job Description:

Are you seeking a personalized tape, hypnosis-by-phone, or an office appointment?

Purpose of Hypnosis - Describe the problem(s) and/or goal(s) you wish to accomplish:

How long have you had this problem or goal?

Have you received medical treatment, psychotherapy, alternative therapy, or other counseling?
If so, please provide details of reason for the treatment and results obtained.

Describe your current health and medical history (if pertinent):

Please list current medications: (if pertinent)

Have you ever been hypnotized before?
(if yes, please describe experience)

What are your expectations of hypnosis