Better Living Through Hypnotherapy     Take Control Of Your Life!   314-831-6766 * By Appointment Only * info@blth-hypnosis.com

Serving The Public With The Most Modern, Effective Hypnotic Methodologies While Using Positive Therapeutic Suggestions Approved by the National Guild Of Hypnotists NGH and is a proud member of the American Diabetes Association ADA & the National Federation of NeuraLinguistic Psychology NLP

Thank you for visiting our "Client Release Form" Page. You may either click here for a printable copy that you will have to mail into us or complete the short form below, hit the submit button and we'll automatically receive it via email. CLIENT'S INFORMATION First & Last Name:  Full Address: Your Email: Home Phone Number: Work Phone Number: Cell Phone Number: Type Of Service: Please Choose One Lose Weight Stop Smoking Improve Grades Improve Memory Improve Study Habits Relieve Test Anxiety Eliminate An Unwanted Habit Control Eating Habits Experience Painless Childbirth Combat Pain Increase Self-Confidence Reduce Stress Improve Athletic Performance (All Sports) Overcome Fears & Phobias Children's Problems Remove Dental Fears Help Control ADD/ADHD End Bed Wetting End Nail Biting Pass Exams Increase Concentration Achieve Self-Acceptance Overcome Insomnia Improve Learning Skills Public Speaking Become Success Conscious Overcome Depression Arrest Procrastination Increase Sexual Enrichment Increase Sales Motivation Regression Therapy Trichotillomania (Pulling out/Twirling hair) Other - Will Explain Below DOCTOR'S INFORMATION Your Doctors Name: Doctor's Address: Work Phone Number: Cell Phone Number: Doctors Email: I   AgreeDisagree   with the following statement. I do hereby agree and understand that hypnotherapy is not a replacement or a substitute for medical treatment. I further understand and agree not to discontinue medical treatments and/or medication without the approval of my physician. It is understood that I will immediately discontinue the use of hypnotherapy upon the advise of my physician. Additional Comments:

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