ARE YOU READY TO CONQUER YOUR NEGATIVE ISSUES / PHOBIAS? (CONFIDENTIAL)
Answer the questions below and we'll let you know!
*Mandatory field

1. *Email address:
2. *Forename:
3. *Surname:
4. Known as:
5. *Post code:
6. Contact telephone number
(incl. STD code): [PREFERRED]
7. *Age:
9. Sex:
10. *Is your work stressful?
11. *Are you currently taking any medication?

12.
If you answered "yes" to the above question, please list any medication you are currently taking here:

13.
*From which of the following health problems do you suffer, if any (please check any or all that apply)?
None
Heart Problems High Blood Pressure
Epilepsy Diabetes
Asthma Ulcers

Other(s) (please specify in the space below):

14.
*Have you ever consulted a doctor or medical professional for any mental condition?

15.
*Are you currently under the care of a Doctor?

16.
*What would you describe your problem to be?

17.
*How long have you had this condition?
Year(s) Month(s)
18. *When were you first aware of the condition?
19. *Do you know or have an idea as to why you might have this problem?

20.
If you answered "Yes" to the above question, please give details here:

21.
*How often do the symptoms of this condition occur?

22.
*When or where are you when the symptoms usually occur?

23.
*How does this condition affect your life?

24.
*When we have helped you solve this issue, what positive difference will it make to your life?

25.
*How will you know that this problem has been solved?
26.
*What have you tried so far in order to try and solve this problem?

27.
*How did you hear about Three Counties Advanced Hypnotherapy Centres?

28.
If you selected "Other" in response to the above question, please specify here:

29.
If we were recommended to you, please enter the name of the person who recommended us:

30.
If you would like a free telephone consultation, please enter your contact telephone number(s) and preferred time(s) here:

31.
If you have any concerns about hypnosis and / or dealing with this problem, please enter them here:

32.
Please tick any other services you might be interested in:
Stopping smoking Easy weight loss
Confidence Compulsions
Addictions Letting go of negative emotions
Eliminating bad habits Panic attacks
Corporate packages  

Other(s) (please specify in the space below):
   

© Three Counties Advanced Hypnotherapy Centres, Norfolk House East, 499 Silbury Boulevard, Central Milton Keynes, MK9 2AH UK Telephone: 01908 488 260 or 0800 0 19 13 66