Name
*
First Name
Last Name
Your preferred email address:
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select any places that make you feel relaxed. You can select them all if they are all relaxing places for you!
*
Beach
Waterfall
Garden
Bush
Lake
Forest
Other
Have you ever tried hypnosis or hypnotherapy before?
*
No
Yes, with a stage hypnotist or street hypnotist
Yes, with a hypnotherapist
Yes, using YouTube, audio downloads etc. or a book
Other
Do you have any fears or phobias?
*
Do you have epilepsy, a respiratory or heart condition, schizophrenia, personality disorder, bipolar depression, or psychosis, hallucinations or delusions, or any other physical or mental health condition that may impede your suitability for hypnotherapy?
*
Yes
No
I'm not sure
Thank you!
Thanks for applying for a position in the 6 Week Weight Loss Program. I will be in contact with you to let you know if there is enough availability for you to join and to make sure you're a good fit for the program.
Submit
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