Please provide the following

Please provide the following (*required)

First Name*

Last Name*

Address*

City*

State / Province*

Postal Code*

Daytime Phone*

E-mail*

Home phone

Your Specific Needs

Hypnosis and Hypnotherapy are a personalized type of therapy and we would love to answer any questions you have regarding your personal situation and goals. Please fill out the form below so we know more about you. Then we will get back to you as soon as possible.

1.	Which Program(s) are you interested in?

	(Select all that apply.)
	Weight loss
	Smoking Cessation
	Alcoholism
	Drug Addiction
	Obsessive Habit
	Phobia
	Pain Management
	Reduced Pain in Childbirth
	Stress/Anxiety
	Attention Deficit Disorder
	Depression

2.	Please give details about your problem or self-improvement goals. This is confidential, only your program counselor will see it. Please include information such as how this problem has effected your life and why you are choosing to overcome it now.

3.	What is the best time to call you?

4.	Where did you hear about us?

	(Select all that apply.)
	Link on the Internet - From Yellow Pages
	Newspaper -Florida Times Union
	Newspaper - Mandarin Newsline
	Newspaper - Other
	Link on the Internet - Other
	Web Search - Yahoo
	Web Search - Google
	Web Search - Other
	Referral - from a friend
	Referral - from a medical or mental health office
	Referral - other
	Telephone book
	Other

5.	How far are you willing to travel to your nearest clinic location? (in minutes or miles)

6.	So that your therapist can have a little early insight into how you are already thinking we'd like to ask you this: What kinds of words have you said to yourself, images you've pictured and feelings have you had that helped you to make the decision now to make this change in your life with us?

7.	Why have you chosen to contact us? How did we earn the honor of your inquiry? Was it the quality of our therapists, the amount of information on our web site? have you heard good things about our reputation? What made you click the "contact us" button?