Booking Form

CONSULTATION REQUEST

Please Fill Out This Form Completely To Request Your Free Consultation
Full Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Were you referred to me?*

YesNo
If yes, who referred you?*
Have you been diagnosed by a medical professional with any of the following? (check all that apply)*

Major clinical depressionBipolar DisorderSchizo-Affective Type DisordersBorderline Personality DisorderNone of the above
I understand that hypnosis sessions do not constitute counseling or therapy.*

I understand
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?*
How long have you been affected by this issue?*
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?*
Once I have approved your application, I will send you an email with a link to schedule your appointment.*

Understood!
Should be Empty:

CONSULTATION REQUEST