Hypnosis Solutions - Guaranteed

Dr. Leo Gagnon, Ph.D.

Hypnosis and Hypnotherapy

Confidential Weightloss Information Form

I will help you lose weight and create a life style that
will keep it off! Your First Visit Is FREE!
Please check those fields that apply to you.
This form will come directly
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:

Your Weight Problem May Be A Result of Bad Eating Habits
PLEASE ANSWER THE FOLLOWING QUESTIONS:

Why Is It Important For You To Lose Weight?
Is Keeping The Extra Pounds Off Important? Why?
Why Have Diets Failed You?
How Much Weight Do You Want To Lose?
Do You See Yourself As:


Do You Feel FOOD CONTROLS YOU?	Yes No
I Want To Stop My SUGAR ADDICTION:	Yes No
I Want To Stop SNACKING:	Yes No
I Eat LARGE PORTIONS:	Yes No
I Eat SECONDS:	Yes No
I Eat DESERTS:	Yes No
I Eat FATTY (JUNK) FOODS:	Yes No
I Love CARBOHYDRATES-BREAD, POTATOES, PASTA:	Yes No
ALCOHOL May Be A Part Of My Weight Problem:	Yes No

If Emotions Rule Your Life Emotions Also Rule Your Eating Habits
PLEASE ANSWER THE FOLLOWING QUESTIONS:


I Have Hurtful MEMORIES:	Yes No
I Am Often SAD:	Yes No
I Often Have DEPRESSION:	Yes No
I Think I Am An ANGRY Person:	Yes No
I Tend To Be FEARFUL, AFRAID OR SCARED:	Yes No
I Tend To Have ANXIETY:	Yes No
I Am Often NERVOUS:	Yes No
I Feel JEALOUS:	Yes No
I Feel GUILTY:	Yes No
I Am GRIEVING:	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 Have THOUGHT ABOUT SUICIDE 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!

CLICK ON ANY FORM BELOW TO SEND ME YOUR INFORMATION:

Click Here To Tell Me What You Want to Change
Your Information Is Always Kept Confidential

Click Here To Send Me Your Confidential
Weight Loss Information

Contact Me With Any Question

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