1. What do you like to be known as

 2. Your Contact Details

First Name

Last Name

Phone Number

 3 Please confirm that you are over the age of 18

 4 How Long have you been smoking ?

 5 Why do you want to quit smoking ?

 6 Have you ever tried quitting before ?

 7 Have you ever had Hypnotherapy before ?

 8 Do you have any physical conditions that make lifting your arms awkward ?

During the Hypnotherapy there is a technique that is sometimes used as a deepener that involves holding your arm up so if you have limited mobility or an ongoing injury then I will use an alternative to this.

 9 Is there a particular time more convenient for your appointment?

You will need at least 90 minutes for the first session and 60 minutes for the second

 10 Do you have any questions about the sign-up process ?

 11 Are you 100% motivated to become a non smoker ?

Thank you for filling out the booking for please book your first session below.

Your second session will be booked at a mutually convenient date and time after completion of the first session