Weight Loss • Chronic Pain • Excessive Drinking • Drug Abuse • Break Ups
Phobias • Gambling • Depression • Stress • Memory Improvement
Please complete this registration form and choose one or more of the following:
Name: Marital Status:
Address: City/State/Zip:
DOB: Age: Occupation:
Home: Work: Cell: Email:
Have you ever seen a (check all that apply)        
If yes, please give their name(s):
Where did you hear about us? (check all that apply)      
How were you referred to
Dr. Smith?
Who is your physician and what is their specialty?
Physician's office location (City/State/Zip/Phone):
Do you object to us contacting him or her about your success?
Do you spend more than $100 a month on smoking?
Describe how smoking controls or interferes in your life?
Which of these fears do you have of stopping smoking? (Please check all that apply):
Do other members of your family smoke?
Do you have a smoking related illness?
Please Explain:
How many cigarettes/pack(s)
per day?
Number Years Smoking?
Circle the strongest desire to stop smoking, with 10 equaling the strongest.
List three reasons why you want to stop smoking:
List three places or situations in which you smoke the most:
1.      2.      3.
What methods have you used to stop smoking before?
Did you stop?
For how long?
Do you have any of these symptoms for which short term counseling techniques may be useful? (Check all that apply)
Complete and submit this registration form and secure your private consultation for only $35.00. After you submit this form you will have the opportunity to make that payment. Also call the office at 334-213-0054 to arrange your appointment.
For Weight Loss Only
Our unique program can quickly eliminate the cravings for unhealthy foods; reduce portions, and stops eating from stress and boredom.
Give three reasons why you are overweight?
1.      2.      3.
How much weight have you decided to lose?
If you successfully lost 20 lbs. or more in the past, how did you do it?
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