General Registration | Hypnosis By Doctors :Hypnosis by Doctors

General Registration

Strictly Confidential

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

Take a few minutes and complete this short form BEFORE your FREE Screening from your Mobile Phone or by Zoom.
Date*
MM slash DD slash YYYY
Please choose one of the following below:
- I rather have a phone consultation
- I rather have a zoom consultation
First Name*
Last Name*
Age*
Marital Status*
Occupation*
City & State
Phone*
Email*
Where did you hear about us? (Check all that applies)*
- Google
- Friend
- Facebook
- Radio
- Other Social Media
- Physician Referral
- Other
Describe your unwanted habit(s) and emotional issue(s) that you are struggling with and have your ever gotten relief?*
Please Return to the Registration Page and See Testimonials Before Your Appointment.
(Please call or text when you complete this form to schedule a free consultation. Some Evening Appointments Are Available.
3342335610
Listen to the Free Sample of the Clinical Hypnosis Recording on the Registration Page.

WEIGHT LOSS

PAIN & MIGRAINE

STOP SMOKING

ANXIETY & DEPRESSION

ALCOHOL & DRUGS

GAMBLING

Dr. Clinton W. Smith, Psy.D

Psychologist & Hypnotherapist

For Assistance:

Call Us: (334)233-5610
Email Us: DrClintonWSmith@gmail.com
Office Address: 495 St. Luke Drive Montgomery, AL 36117

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