Richard Nicholls DHP MAPHP MNCH (Reg.) Cert.SH.Inst

Free Hypnosis Application Form

Richard Nicholls DHP MAPHP MNCH (Acc.) Cert.SH.Inst
Tel: 024 7639 8439
E-mail: richard@midlandshypnotherapy.com

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 Ł15k
Ł16k - Ł25k
Ł26k - Ł40k
Over Ł40k

5.) Issues

Smoking
Weight Control
Confidence
Anxiety
Alcohol
IBS
Insomnia
Stress
Other

6.) Please indicate whether you wish to be considered for Free Hypnosis, Free Hypnotherapy or Reduced Rate Hypnotherapy
Waiting list length is indicated at the bottom of this page.

Free Hypnosis
Free Hypnotherapy
Reduced Rate Hypnotherapy

Many Thanks.

Once approved, you will have access to free hypnosis audio tracks to download, CD copies are also available at request.

If approved for Free Hypnosis, you may also be entitled to a free face to face hypnotherapy appointment in Tamworth, and may also be entitled to reduced rate sessions for further appointments.

Waiting list info

Free Hypnosis, Download or CD. Available now.
Free Hypnotherapy (2 sessions), Approx. 4 month wait
Reduced Rate, (Usually half, please enquire to confirm) Approx. 6 week wait.

Š 2007 Richard Nicholls.