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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.

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