Full name:

Street address:

City, State & Zip Code (or Province and Country):

E-mail Address:

Age:      Gender: 

Marital Status:

Children?  How many?

Home Phone:

Business Phone:

Are there any other smokers in your household?

What is motivating you to become a non smoker?

The benefits do you hope to gain by becoming a non smoker:
(Please be specific)

    My health will be improved because:

    My self-esteem will increase because:

    I will feel guilt-free because:

    My personal appearance will improve because:

I will stop wasting money.  I will save $           per month as a non-smoker.

    List other benefits:

Started smoking at age:

Brand you currently smoke:

How many cigarettes per day are you currently smoking?

Other forms of tobacco used:

When is the urge to smoke the strongest?

When do you actually smoke the most?

Have you tried to stop smoking?

By what means?

How many times?

If you've quit before, detail reasons you resumed smoking:

Do you think giving up cigarettes will create a sense of vacancy or a void in you?

Is there anything that you fear will deter you from breaking the smoking habit?

Is weight gain a concern of yours?  Explain:

Will you listen to a reinforcement CD every day for at least 21 consecutive days?
(If time is at a premium, you can always listen at bed time, the last thing you do before falling asleep)

Would you be willing to practice a 3-minute breathing exercises twice, daily?

Questions or comments:

 

Are you seeking a personalized tape, hypnosis-by-phone or an office appointment?

 

Describe your current health and any pertinent medical history:

Current medications: (please list, if pertinent)

Have you ever been hypnotized before?
(if yes, describe experience)

Describe your expectations of hypnosis:

All information about you will remain strictly confidential.  Successful, lasting results may require several sessions. You may be asked to practice self-hypnosis or listen a reinforcement CD. You are responsible for actively cooperating with, and participating in, the success of your program. You control your success. Hence, neither Carol Denicker,  North Shore Hypnosis,  or the Holbrook Wellness Center shall be held accountable for the results you attain.  You may be referred elsewhere for treatment, or have your hypnosis program terminated if deemed appropriate.