Please Fill Out This Form Completely To Request Your Free Consultation
Were you referred to me?
If yes, who referred you?
Have you been diagnosed by a medical professional with any of the following? (check all that apply)
Major clinical depression
Schizo-Affective Type Disorders
Borderline Personality Disorder
None of the above
I understand that hypnosis sessions do not constitute counseling or therapy.
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.
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