Disclaimer: Individual results may vary. All services on this website are educational in content, provided in good faith and are not medical or psychological advice.  We do not diagnose treat or cure. Content on this site is not a substitute for medical or psychological treatment.

                                                                       ADVANCED HYPNOTHERAPY                                                                                                                                              Lynn Whitmire C.Ht.                                                                                                                                                            810 Emerald Street, Suite 102                                                                                                                                                            San Diego, Ca. 92109

                                                                                     (858) 270-5756
                                                     

                                                     Client questionnaire (All information is strictly confidential) 

Name:____________________________________________________________________________________________

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Address:__________________________________________________________________________________________

City:_________________________________________________Zip_____________ 

E-Mail Address___________________________________________________________________________________________

OK to send updates via E-Mail? Yes__________  No________

Married: _____Single: _____Divorced: _____Widowed: ______

Birthdate:___/___/___Male: ______Female:_____ 

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

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What other methods have you tried? 

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Any Psychological or Medical treatment. Medications? 

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Other pertinent information necessary in achieving your outcome? 

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