Smoking Cessation Form

Stop Smoking

Please fill in the following questionnaire at least a day before your appointment.

The more information you give us in the large boxes, the better. It helps us to give you a really good session and it also saves us time for the work that needs to be done. We want to make every minute count. Your information is automatically sent to us by email. After you fill out your form, make sure to prepare for your session by following the suggestions below.

For session costs, please see Pricing. Payment is due on the same day of our session. Payment is due on the same day of our session. I accept cash, check or credit card. Please note: We respectfully request at least 24 hour notice for cancellations or rescheduling of appointments. There is a $100 no show fee.

Preparing For Your First Session:

If you’ve already made your appointment, then we look forward to meeting you. If you haven’t made an appointment and just sent us your form, please make your appointment by clicking below:

Tips For a Really Good Hypnosis Therapy Session:

  • Have the attitude that you truly want to benefit from our session. This attitude is a hundred times better than choosing to resist hypnosis. Hypnosis works because you want it to. You don’t even have to believe in it. Just want what you are coming in for.
  • Have eaten something earlier with some protein in it so that you are very comfortable and your mind is able to focus on what we are doing. Be sure to skip coffee or any other beverage that contains caffeine.
  • Wear comfortable clothing.
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