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
Sex*
Marital Status*

SDSep.Wid.
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 except 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 )
Stop Smoking
How long have you been smoking?*
How many packs a day?*
How many times have you tired to quit smoking before?*
List previous efforts you’ve taken to stop smoking in the past.
Check if your smoking 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?*
Does your family support your stop-smoking efforts?*
Is your family excited about your quitting smoking with hypnosis?*
Can you remember when you did not smoke?*
What do you remember about not smoking?
What do you think causes you to smoke?*
What is the #1 reason you want to quit?*
List 5 positive benefits you get by eliminating your problem: 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 ControlOther
First & Last Name*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MTU Hypnosis - Stop Smoking, Vaping, Chewing Intake Form

Stop Smoking