SESSION REQUEST 
NLP, HYPNOSIS, AND BREAKTHROUGH SESSIONS
Yes! I am interested in taking my life to the next level!  Please consider my application and, if accepted, contact me for a consultation call to find out if I'm a good fit for one of these sessions.  I understand there is a $100 fully refundable application fee, which will either be applied to my session or refunded if I am not accepted or choose not to book a session. I will only lose the deposit if I miss the scheduled consultation call I agree to, so I will be on the call once it's scheduled.
Please complete this confidential profile and submit it as soon as possible. We must receive your completed form at least 24 hours before your scheduled consultation.
Please submit your completed form by hitting the 'Reserve Now' button at the bottom of the form. To protect your privacy, DO NOT EMAIL THIS FORM. Submit your information by hitting the 'Reserve Now' button once. 
 Step #1: Client Information
Full Name (Client's First and Last):
Parent or Guardian Name (re'd if Client is under 18 years old):
Date of Birth:
Email Address:
Phone Number:
 Step #2: Starter Questions
How did you hear about us?
Does the Client desire an Individual NLP/Hypnosis session, Breakthrough session or currently unknown?
Please describe any previous experience with NLP, Hypnosis, Coaching, EFT, or Energy Work.
Is the Client currently under the care of a Psychotherapist, Physician, Pathologist, or Licensed Medical Practitioner for this issue?
If yes, please explain the condition(s) for which the client is being treated and the nature of the treatment(s).
 Step #3: Session Specific
Please list what the Client looks to achieve as a result of the session, including things to release or change and aspects to aquire:
How will the Client know when the session what a complete success?  What is the desired outcome?
Please describe any relevant behavior, emotional issues, or significant emotional events during the past 3 years:
Please include any additional information which you believe may be relevant to the current struggle(s)/desire(s):
 Step #4: Reserve Your Request
Item
Price
$100
Credit Card Number:
CVC Code:
Expiry Month:
Expiry Year:
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All orders are through a very secure network. Your credit card information is never stored in any way. We respect your privacy...
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