Personalised hypnotherapy form to help Stop smoking

Smoking cessation personalised tailored mp3 order form

Please complete the form below to start your order for a fully tailored and personalized smoking cessation hypnotherapy downloadable mp3 to help you stop smoking. I may contact you by email if I have any questions for you before I record your session, if you have any objection to this please indicate so in the last box.

Stop smoking personalised mp3 form

Name

Email Address

Select your age

Select type of session you would like

Your Phone number (Optional)

select your gender

Select how long you have been trying to stop smoking

Do you suffer from any allergies? If yes please give details.

Do you take any mind altering medication? If yes please give details

Please give me details about your difficulty in stopping smoking. Including anything you may think is relevant. The more infomation you give me, the better chance you have of Stopping.