The Nations #1 SuccessMaker Since 1976

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Confidential Information Form

Use This Form To Help Me Know
How I Can Help You

I Will Call You Soon
CLIENT CONTACT INFORMATION:
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* First name:
* Last name:
* Email:
* Address:
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* Zip Code:
   Country:
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* 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

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Thank you for your confidence in me. I will call you as soon as I can.
Dr. Leo Gagnon
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