Form

Online Appointment Request

Using the Online Appointment Request is quick, easy, and available 24 hours a day.

Thank you for scheduling.
First Name*
Last Name*
Daytime Phone*
Cell Phone
Evening Phone*
E-mail*
How did you learn about my office?*
Client Type*

New Client Returning Client
Returning Client, what YEAR were you last in?
Why do you want to be hypnotized?*
SCHEDULING PREFERENCE - I recommend a program of three sessions because it has proven to be more successful than a single session. (Drop Down Menu)*
Preferred Days

Monday Wednesday Any Tuesday Thursday
Preferred Times

12:00 noon 4:00 p.m. Any 1:30 p.m. 5:30 p.m.
Should be Empty: