Booking Form

Full Name *

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email *

example@example.com

Were you referred to me?

Yes No

If yes, who referred you?

I have NOT been diagnosed with major clinical depression, Bipolar Disorder, Schizo-Affective type disorders, or Borderline Personality Disorder. I understand that these hynosis sessions do not constitute counseling or therapy.

I do NOT have the above diagnoses I have been diagnosed with one of the above.

What issue are you interested in resolving?

How has this impacted your life in the past? (missed events, relationships, money, etc)

How is this issue impacting your life right now?

On a scale of 1-10, how committed are you to resolving this problem?

How does it make you feel when you think about letting this go once and for all?

How do you feel about investing in yourself?

Please list 3 convenient times for a connection call and we will be in touch to schedule.

Connection Call Application