Name: Hypnosis by Doctors
Address: 495 St Lukes Drive, Montgomery, AL, 36117
Telephone: +13342130054
Price range: $

We appreciate the confidence you place in us to resolve your lifestyle issues without medication.

Complete this registration form before your initial consultation. The information you provide will be utilized to develop a personal plan and to optimize a positive outcome. This content and our interactions are strictly confidential.
Date*
MM slash DD slash YYYY
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*

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Address*
City*
State*
ZIP*
Home Phone*
Mobile Phone*
Email*

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Do you spend more than $100 a month on smoking?
- Yes
- No
Describe how smoking controls or interferes in your life?
Which of these fears do you have of stopping smoking? (Please check all that apply)
- Weight Gain
- Withdrawal
- Giving Up Best Friend/Crutch that can't stop
- None
How long have you been smoking?
How many cigarettes/pack(s) per day?
Have you tried to quite before?*
- Yes
- No
How many times?
What methods failed to help you quit smoking?*
Is your smoking making you physically uncomfortable?*
- Yes
- No
Are you embarrassed by your need for a cigarette?
Does your smoking limit you or your activities?*
- Yes
- No
Do you feel your smoking controls you?*
- Yes
- No
Is successfully quitting smoking a top priority? Explain.
What new activities will you become involved in after you quit smoking?*
Did you know hypnosis is 100% safe?
- Yes
- No
Does your family support your stop-smoking efforts?
- Yes
- No
Is your family excited about your quitting smoking with hynosis?*
- Yes
- No
Do you feel tired, run down, and out of energy?*
- Yes
- No
Can you remember when you did not smoke?*
- Yes
- No
What do you remember about not smoking?*
Has smoking caused you pain or suffering yet? Describe physical or emotional.*
What is the number one reason you want to quit?
What is the most important element in deciding to use our service?*
- Effectiveness (Your results)
- Service (How we respond to your needs)
- Time (How fast you get results)
- Affordable (What we charge)
Choose the strongest desire to stop smoking, with 10 equaling the strongest.
List three reasons why you want to stop smoking:
List three places or situations in which you smoke the most:
1. 2. 3.
Do you have any of these symptoms for which short term counseling techniques may be useful? (Check all that apply)
- Weight Loss
- Pain Management
- Sexual Dysfunction
- Depression/Anxiety
- Excessive Drinking
- Anger
- Nail Biting
- Phobias/Fears Insomnia
- Stress
- Overcoming A Breakup
- Memory

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Are you overweight?*
- Yes
- No
Our unique program can quickly eliminate the cravings for unhealthy foods; reduce portions, and stops eating from stress and boredom.
Give three reasons why you are overweight?
How much weight have you decided to lose?
If you successfully lost 20 lbs. or more in the past, how did you do it?
Please choose one of the following below:
- I would rather have a phone consultation
- I would rather have a zoom consultation
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Please Return to the Registration Page and See Testimonials Before Your Appointment.

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Stop Smoking Registration

Strictly Confidential

Please Return to the Registration Page and See Testimonials Before Your Appointment.

WEIGHT LOSS

PAIN & MIGRAINE

STOP SMOKING

ANXIETY & DEPRESSION

ALCOHOL & DRUGS

GAMBLING

Free Weight Loss Registration Form

Free Stop Smoking Registration Form

Free General Registration Form

REGISTER NOW FOR A FREE
HYPNOSIS SCREENING WHEREVER YOU ARE!

We Get Results Online Since 2007! Review our Testimonials and See For Yourself…

Dr. Clinton W. Smith, Psy.D

Clinical Psychologist & Hypnotherapist

For Assistance:

Stop Smoking Registration

Strictly Confidential

Please Return to the Registration Page and See Testimonials Before Your Appointment.

WEIGHT LOSS

PAIN & MIGRAINE

STOP SMOKING

ANXIETY & DEPRESSION

ALCOHOL & DRUGS

GAMBLING

REGISTER NOW FOR A FREE HYPNOSIS SCREENING WHEREVER YOU ARE!

We Get Results Online Since 2007! Review our Testimonials and See For Yourself…

Dr. Clinton W. Smith, Psy.D

Clinical Psychologist & Hypnotherapist

For Assistance:

REGISTER NOW FOR A FREE
HYPNOSIS SCREENING WHEREVER YOU ARE!