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*
Month
Day
Year
Please choose one of the following below:
- I would rather have a a phone consultation
- I would rather have a zoom consultation
First Name*
Last Name*
DOB*
Month
Day
Year
Age*
Marital Status*
Occupation*

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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
Do other members of your family smoke?
- Yes
- No
Do you have a smoking related illness?
- Yes
- No
Please Explain:
How many cigarettes/pack(s) per day?
Number Years Smoking?
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.
What methods have you used to stop smoking before?
Did you stop?
- Yes
- No
For how long?
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

WEIGHT LOSS