Confidential Form

Dr. Leo Gagnon, Ph.D.

Hypnosis and Hypnotherapy

Confidential Information Form

I will help you get what you want!
Please check those fields that apply to you.
I will get back to you soon.
This form will come directly and
securely to me when you click on submit.

CLIENT CONTACT INFORMATION:

Items with * are required fields.

* First name:
* Last name:
* Email:
* Address:
* City:
* State:
* Zip Code:
Country:
Cell Phone:
Work Phone:
* Home Phone:

PLEASE ANSWER THE FOLLOWING QUESTIONS:


I Want To Stop The HURTFUL MEMORIES:	Yes No
I Want To Stop The SADNESS:	Yes No
I Want To Stop The DEPRESSION:	Yes No
I Want to Stop The ANGER:	Yes No
I Want to Stop The FEAR/AFRAID/SCARED:	Yes No
I Want to Stop The ANXIETY:	Yes No
I Want to Stop The NERVOUSNESS:	Yes No
I Want to Stop The JEALOUSY:	Yes No
I Want to Stop FEELING GUILTY:	Yes No
I Want to Stop The GRIEVING:	Yes No
I Want to Stop THINKING ABOUT HIM/HER:	Yes No
I Want To STOP SMOKING:	Yes No
I Want To STOP CHEWING TOBACCO:	Yes No
I Want To LOSE WEIGHT:	Yes No
I Want to Stop My SUGAR ADDICTION:	Yes No
I Want to Stop The DRINKING ALCOHOL:	Yes No
I Want to Stop My DRUG PROBLEM:	Yes No
I Want More SELF CONFIDENCE:	Yes No
I Want to Stop The OBSESSIVE COMPULSIVE BEHAVIOR:	Yes No
I Want A Better SEX LIFE:	Yes No
I Want to SLEEP BETTER:	Yes No
I Want Less PHYSICAL PAIN:	Yes No
I Want Less EMOTIONAL PAIN:	Yes No
I Want Less STRESS:	Yes No
I Have An UNHAPPY RELATIONSHIP:	Yes No
I Think of or have ATTEMPTED SUICIDE:	Yes No
I Have Suffered ABUSE:	Yes No
I Don't TRUST OTHERS:	Yes No

ADDITIONAL COMMENTS
* Please Type Your Signature:
How Did You Hear About Us?:
Is There A Good Time To Call You?
Your Time Zone Is:

The purpose of this form has been to briefly assess your needs. I will call you so we can will determine your needs. If you only need one session then that's what we'll do. On your first visit with me I will also do a mini-hypnosis-session for you.

I want to talk with you as soon as possible so I can help you achieve what you want so please be certain I have a phone number where you can be easily reached.

Thank you, and I really look forward to improving your life as I have done with thousands before you.

Dr. Leo Gagnon

You May Only Need One Session!

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