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

. I confirm that i'm over 18

4 How Long have you been smoking ?

5 Why do you want to quit smoking ?

6 Have you ever tried quitting before ?

. Yes

. No

7 Have you ever had Hypnotherapy before ?

. Yes

. No

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.

. Yes

. No

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

. Daytime

. Evening

. Either

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

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

. Yes

. No

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