ALL INFORMATION IS STRICTLY CONFIDENTIAL.

DATE:

Name:

Phone:

Email address:

Street address:

City:

State:

Zip:

Date of birth:

Sex: Male Female

Marital status: Single Married Divorced Widow

Number of children

Occupation:

Education:

Your medical history (allergies/surgery/addictions/diseases):

May we notify your doctor of your desire to use hypnosis to quit smoking?

Why you want to quit smoking? Please list your reasons in order of importance:

Have you ever been hypnotized before? If yes, under what circumstances?

Do you have any fears concerning hypnosis? If so, please list them in order of importance:

Do you know anyone who has derived benefits from hypnosis? (Please explain):

How did you hear of Dr. Inessa K. Zaleski?