MTU HYPNOSIS - Stop Smoking, Vaping, Chewing Intake Form

MTU Hypnosis - Stop Smoking, Vaping, Chewing Intake Form
Name
Home Phone
Format: (000) 000-0000.
Cell
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Accept Texting?
E-mail
example@example.com
Address

Address

Street Address Line 2

CityState / Province

Zip
Emergency Contact
Phone
Format: (000) 000-0000.
Age
Birthdate

MonthDayYear
Date
Marital Status
If children, what are their ages?
Highest education level completed
Occupation
Doctor’s Name
Phone
Format: (000) 000-0000.
Complete Address
Are you under a doctor’s care now?
Indicate any current health problems - any medications currently taking & their purpose
Have you ever been psychologically treated for an emotional/behavior problem?
If yes, are you currently receiving treatment or counseling?
Provider name
Phone
Format: (000) 000-0000.
Complete Address
Do you have light sensitive epilepsy?
Do you wear contact lens?
Dentures?
Do you exercise?
How often?
What type?
What do you expect from hypnosis?
If you have ever been hypnotized: indicate private or group/purpose/result?
Do you know anyone personally who has used hypnosis to improve or change his or her life?
How did you find MTU Hypnosis?
If you have any fears, concerns, or questions about hypnosis — please describe
Did you know hypnosis is 100% safe?
List your e-mail address if you are interested in receiving our e-newsletter
example@example.com
Select the most important element in deciding to use our services.
How long have you been smoking - vaping - or chewing?
How often do you use it per day?
How many times have you tried to quit ?
List previous efforts you’ve taken to stop using it in the past.
Check if your smoking, vaping or chewing is causing
Activities limited or abandoned such as:
Health problems such as:
Is successfully quitting smoking a top priority?
What new activities will you become involved in after you quit smoking?
Do other family members smoke, vape or chew?
Does your family support you in quitting the habit?
Is your family excited about your quitting the habit with hypnosis?
Can you remember when you did not use nicotine products?
What do you think causes you to smoke, vape or chew?
What is the #1 reason you want to quit?
What 3-5 positive benefits do you get by eliminating your habit: Example: I am more relaxed and at ease even when dealing with stressful situations.
a
b
c
d
e
Where applicable, check the issues you have been dealing with and/or would like to resolve.

Other
First & Last Name
Signature
Date

MonthDayYear
Date
Should be Empty:

MTU Hypnosis - Stop Smoking, Vaping, Chewing Intake Form