Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is your sex?

Male

Female

I would rather not say

What is your relationship status?

Single

Legally Married

In a committed relationship

Do you have prior experience with hypnosis?

Yes

No

What would you like help with?

Addiction

Trauma

Feeling worried

Feeling sadness

Mindset

Fear of something (airplanes, spiders, ect)

Healthier Lifestyle

Improved Attitude

Stress

Relationship issues