MTU HYPNOSIS - Stop Smoking, Vaping, Chewing Intake Form

MTU Hypnosis - Stop Smoking, Vaping, Chewing Intake Form
Name*
Home Phone*
Cell*
Please enter a valid phone number.
Work
Please enter a valid phone number.
Accept Texting?*

YesNo
E-mail*
example@example.com
Address*

Address

Street Address Line 2

CityState / Province

Zip
Emergency Contact*
Phone*
Age*
Birthdate*

MonthDayYear
Date
Marital Status*

SDSep.Wid.Married
If children, what are their ages?
Highest education level completed*
Occupation*
Doctor’s Name *
Phone*
Complete Address*
Are you under a doctor’s care now?*

YesNo
Indicate any current health problems - any medications currently taking & their purpose*
Have you ever been psychologically treated for an emotional/behavior problem?*

YesNo
If yes, are you currently receiving treatment or counseling?

YesNo
Provider name
Phone
Complete Address
Do you have light sensitive epilepsy?*

YesNo
Do you wear contact lens?*

YesNo
Dentures?*

YesNo
Do you exercise?*

YesNo
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?*

YesNo
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.*

Effectiveness ( your results )Service ( how we respond to your needs )Time ( how fast you get results )Affordable ( what we charge )
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*

An Unwanted ExpenseCoughingDiscomfort, Pain, SufferingEmbarrassmentFamily/Work ProblemsFeeling that smoking controls youLimits on Social LifeLow EnergyRun Down FeelingTirednessWinded Breathing
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.*

AlcoholismAngerAnxiousBed WettingCancer/Chemo/RadiationDrug AddictionFear of Flying/HeightsFeeling OverwhelmedGagging ReflexGamblingHabit ControlHigh Blood PressureIBSImproved ConcentrationInfertilityInsomniaJealousyJob Interview AnxietyLearning/ADDMedical/Dental Procedures Performance AnxietyMemory ImprovementMigrainesMotivationNail Biting/PickingNervous StomachNervous TicsOCDOrganizational SkillsOver-Healing/ScarringPain ManagementPanic AttacksPre/Post SurgeryProcrastinationPTSDPublic SpeakingRelationship IssuesSalesSelf ConfidenceSkin ProblemsSmoking CessationSports ImprovementStress ManagementStutteringTeeth Grinding/Jaw ClenchingTension HeadachesTest Taking/Study HabitsTime ManagementTobacco ChewingVappingVertigoVisualizationWartsWeight ControlNone Of The AboveOther
First & Last Name*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MTU Hypnosis - Stop Smoking, Vaping, Chewing Intake Form