New Client Smoking

Main Line Hypnosis
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Age
Gender

MaleFemale
How did you hear about us?

FriendWebsiteDoctorOther
Have you been hypnotized before?
If yes, what was your experience?
How long have you been smoking?
Any previous attempts to quit smoking?

YesNo
How many cigarettes do you have a day?
Why do you want to quit smoking?
On a scale from 1-10 how important is it for you to stop smoking now?
We find it useful to sometimes use a holistic approach (mind-body-spirit) Would you consider yourself a spiritual person?

YesNoMaybe
Medical History
Are you currently undergoing medical or psychological treatment for the above issue?

YesNoOther
if yes, please give Doctors name and brief summary.
Any appointment changes need to be made two business days in advance. Appointments canceled without the 24 hour notice will be charged for the session.

Hypnosis is a powerful state but I can not guarantee any results. What I can do is give you my fullest attention and effort.

Please sign below indicating you understand these policies. If you are bringing a minor under 18 years old, parent or guardian signature is reguired. Thank you.
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Main Line Hypnosis