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Please fill out this short questionnaire.
Fields marked with a * are required.

Have you ever experienced
hypnosis before?
(Check all that apply)

Yes, One-on-one
Yes, in a group
Never

If yes, my experience with hypnotherapy was:

Relaxing and Pleasurable
Successful. I really accomplished my goals
Uncomfortable. No rapport with hypnotherapist
I would like to try hypnotherapy for:

Smoking or some other bad habit
Weight control
Stress Management
Fears, phobias or anxiety
Self Esteem or Confidence
Some other reason

Most Important to me is:

Hypnotherapist's training and credentials
How the hypnotherapist relates to me, personally.
All of the above, equally.
*
*