Application Form for Adults

IMPORTANT, PLEASE READ: 

Fill out the form only if you are ready to make the payment and proceed with the sessions.

Full payment is required 24 hours before the session. If you cancel your appointment prior to your appointment, the money will be fully refunded. However, after using the first session, regardless you use the remaining sessions or not, the fee remains the same and there will be NO refunds. The fee is per program, not per session. Missed appointments without proper prior notice will count as used sessions.

The information you provide is strictly confidential. You get the same confidentially at Virginia Beach Hypnosis as you would get at your doctor’s office. Please answer all the questions with honesty. No need to be shy or embarrassed. I can help you better if I know all the facts upfront.

All fields are required.

I am aware of the cost of the service I am seeking. (Fees Page)

Method of Payment *
Today’s Date *
How did you find me? *
Full name and what would you like me to call you? *
Date of Birth *
Enter as : mm/dd/yyyy
Gender *
Street Address *
City *
State *
Zip *
Phone *
Alternate Phone
Email *
Repeat Email *
Enter the email again please, do not Copy and Paste
Have you ever been hypnotized? *
When, why and what was the outcome?
Are you married or in a relationship and is it a happy one? *
Employer *
Profession/Title or Rank *
Education *
What is your religious belief and do you believe in the afterlife? *
What is your favorite color? *
What activities make you happy? *
What is your happiest memory? *
Where would you like to go on vacation? *
Name something that you are really good at *
Name two of your favorite celebrities *
i.e. Singer, Actor, Athlete
Do you have any pets and if so, name and type of pet? *
Name 3 people that are close to you, and the relationship *
Names and ages of children, if any *
Are your parents alive and how close are (were) you to them? *
Did you have a happy childhood? *
Can you swim? *
Are you allergic to Cats? *
Do you smoke? *
Do you drink alcohol? *
Please select preferred days for sessions *
Chose the preferred time for session *
Describe the current issue *
What year did it start and did anything happen in your life when this problem started?
(Weight Loss ClientsPlease name the foods that contribute to your weight gain. Do you eat pasta, bread, pizza, sweets? How much water do you drink a day? Do you exercise and how often?)
(Smokers – Please mention how long you have been smoking, what you have tried so far to help you quit and why you decided to quit now.)
(For addictions – Please explain why you want to get rid of your bad habit NOW?)
Virginia Beach Hypnosis Terms and Conditions
Agreement to Terms and Conditions *
By checking this box and submitting this application form, I confirm that I have read, understood and agree to the above Terms and Conditions.

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