ADVANCED HYPNOTHERAPY

Lynn Whitmire C.H.T., CT. H.A.

Client questionnaire (All information is strictly confidential)

Name:___________________________________________________

Phone:___________________(H)__________________________(W)

Address:_________________________________________________

City:____________________________________Zip_____________

Married: _____Single: _____Divorced: _____Widowed: ______

Birthdate:___/___/___Male: ______Female:_____

Occupation:_______________________________________________

Who referred you? ________________________________________________________

What brings you in today? (State your desired outcome): ________________________________________________________________________

________________________________________________________________________

What other methods have you tried?

________________________________________________________________________

Primary Physician name and address

________________________________________________________________________

Any Psychological or Medical treatment. Medications

________________________________________________________________________

Other pertinent information necessary in achieving your outcome?

________________________________________________________________________

E-Mail Address___________________________________________________________

OK to send updates via E-Mail? YES__________  NO________