Custom Hypnosis Audio - Details Form

Please complete the form below IN AS MUCH DETAIL AS POSSIBLE. This allows for the language and suggestions used in your audio to be tailored for the most positive effect when listening.

Please allow up to 7 working days for the delivery of your finished audio from the date of submitting this form. If you have not received the download email by then (be sure to check your SPAM / junk folder), then email info@harleystreetstopsmokingclinic.com.

First Name

Surname

What name do you prefer to be called by?

Email Address

What would you like to achieve from using your audio? Please describe in detail.

What currently stops you from changing?

Describe, in as much detail as possible, a SPECIFIC scenario or activity in the future that would most represent your progress in making this change.

Describe, in as much detail as possible, a SPECIFIC scenario or activity in the future that you would be MOST concerned about in relation to staying in control with the issue / maintaining your progress.

Are there any particular subjects, words, phrases, themes or images that you specially DO NOT want mentioned or included in your custom audio?

Have you experience hypnosis / hypnotherapy or used hypnotic audios before? Please give details and how you found the experience.

Please detail anything else about your situation that you believe may be useful to know.

I confirm I do not suffer from epilepsy, irregular heartbeat or have a pacemaker fitted. If being treated for a mental health condition, I have confirmed suitability of the use of hypnotic audio with my doctor or specialist. I confirm I do not suffer from epilepsy, irregular heartbeat or have a pacemaker fitted. If being treated for a mental health condition, I have confirmed suitability of the use of hypnotic audio with my doctor or specialist. I CONFIRM (please tick)

I have read and agree to the 'Terms & Conditions' on this website. I have read and agree to the 'Terms & Conditions' on this website. I CONFIRM (please tick)

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