Free Hypnosis Application

Your Name
Email address
Contact Number
Post Code

1.) Age Group

Under 16
16 - 21
22 - 40
41 - 60
Over 60


2.) Marital Status

Single
In Relationship
Married
Divorced
Widowed


3.) Employment Status

Student
Employed
Self Employed
Unemployed
Retired


4.) Household Income

Under £15k
£16k - £25k
£26k - £40k
Over £40k


5.) Issues

Smoking
Weight Control
Confidence
Anxiety
Alcohol
IBS
Insomnia
Stress
Other

Many Thanks.