Name *

First Name

Last Name

Postal Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Area of interest *

Please indicate which of these areas you would like to work on

Weight Management

Smoking Cessation

Anxiety/Stress Management

Confidence/Self-esteem/Self-image

Motivation/Procrastination

Relationship

Life Coaching

Attitude/Outlook

Study Skills

Fear/Apprehension

Facilitate Wellness

Change Habit(s)

Pain Management

Regression

Do you have a primary care physician? *

Yes

No

Physician Name

If YES

First Name

Last Name

Address of Medical Practice

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you currently suffering from any of the following *

Stress/Anxiety/Depression

Inability to Relax

Sleeplessness

Sexual challenges

Alcohol/Drug abuse

Nightmares

General poor health

Smoking

Compulsive behaviour

Weight management

Inability to focus

Poor memory

Marital/Relationship problems

Recent divorce

PTSD

Current illness

Death of a loved one

Childhood difficulties

Phobias/Fears

Lack of energy

Lack of success