- LifeStyle by Choice -
(ALL INFORMATION IS CONFIDENTIAL
NAME __________________________________________(NICK NAME)_______________ DATE _____________ STREET ADDRESS __________________________________________ STATE _____ ZIP _______________ E-MAIL ADDRESS________________________________________________________ HOME PHONE _____ ______________ CELL PHONE _____ ______________ I give permission to be contacted via e-mail: YES _____ NO _____ Home Phone: YES _____ NO _____
Cell Phone: YES _____ NO _____ BIRTHDATE _____________________ Age _____ MALE _____ FEMALE _____ EMERGENCY CONTACT _________________________________________ PHONE _____ Have you been hypnotized before? _____ When __________ Results ___________________________________________ At what age did you start using tobacco products? _____ Did your mother or father use tobacco products? Mom _____ Dad _____ Comment ___________________________ Will any other member of your household still be using tobacco products? _____ Who? _____________________________ Have you used other types of treatment for the above issue? YES _____ NO _____ If you have please indicate the type of treatment and its effectiveness: Are you experiencing any mental health issues at this time? YES ______ NO ______ Please explain below: Are you taking medication for the above? YES _____ NO _____ Please explain type(s) below: Have you ever been treated for any of the following? CHECK IF YES.
Arthritis _____ Diabetes _____ High Blood Pressure _____ Heart trouble _____ Seizures/Epilepsy _____ Obesity_____
Anxiety _____ Stress _____ Depression _____ Broken Bones _____ Other ______________________________________ Do you feel that you can gain control of the issue that you are here for today? YES _____ NO _____ EXPLAIN BELOW AGREEMENT I am willing to be guided through mental and physical relaxation techniques, visual imagery, hypnosis, and or Neuro-Linguistic Programming (NLP). I understand that there are no guarantees for changing human behavior through this process. I also understand that the services I purchase from LifeStyle by Choice, LLC are not to be used as a substitute or replacement for professional medical or mental health advice or care. SIGNATURE __________________________________________ DATE ______________
Name: ________________________________________ Date: ___________ Why did you start smoking? Where, what locations, do you smoke throughout your day? What time(s) of the day do you smoke?
At what time and where do you have your first cigarette? TRIGGERS (Leave this part blank – do not write below this sentence)
Daily Triggers – Sporadic Triggers – Emergency & Instant Triggers -