Please take a few minutes to complete this form, it will help me get to know a few things about you before our meeting.
I am sure there are many other things you would like to discuss, and there will be ample time in our session for this.
By sending this information, I understand that if I have any medical or mental problems, or under a Doctor’s care, or on any medication,
I will check with my Doctor BEFORE changing my regular diet, exercise habits or any life changes. I also understand that I am responsible
for my own behavior, and that going through this Hypnotherapy program does not guarantee success or refund.
THE INFORMATION ON THIS FORM IS STRICTLY CONFIDENTIAL