General Registration

Free Consultation Registration Form

Complete this free general registration form before your free consultation. We will contact you to set an appointment when we receive your submission. All information is confidential and only seen by Dr. Smith.

Chronic Pain • Weight Loss • Stop Smoking • Excessive Drinking • Drug Abuse • Break Ups
Phobias • Gambling • Depression • Stress • Memory Improvement

Please review the testimonials after submitting your form.

  • Take a few minutes and complete this short form BEFORE your FREE Screening from your Mobile Phone or by Zoom.

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  • *See Testimonials Before Your Appointment at : Testimonials Page.

  • *Listen to the Free Sample of the Clinical Hypnosis Recording on the : Registration Page.

  • *Please call or text when you complete this form to schedule a Free Consultation. Some Evening Appointments Are Available.

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    • WEIGHT LOSS

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    PAIN & MIGRAINE

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    STOP SMOKING

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    ANXIETY & DEPRESSION

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    ALCOHOL & DRUGS

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    GAMBLING

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