Stop Smoking Registration - Hypnosis by Doctors :Hypnosis by Doctors

Stop Smoking Registration

Strictly Confidential

Weight Loss • Chronic Pain • 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
How many cigarettes do you smoke per day?
What is your desire level to stop smoking on a scale from 1-10 ?
The strongest desire represents a 10. My desire is a ______.
Share other details about your smoking or vaping habit?*
*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.
3342335610

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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