Helping People Reclaim Their Happiness Since 1976



LovingMatters Confidential Information Form
I can help you get your life back!
Please check those fields that apply to you.
I will call you as soon as I possibly can.
This form will come directly and
confidentially to me when you click on submit.
CLIENT CONTACT INFORMATION:
Items with * are required fields.
* First name:
* Last name:
* Email:
* Address:
* City:
* State:
* Zip Code:
   Country:
   Cell Phone:
   Work Phone:
* Home Phone:
 
PLEASE ANSWER THE FOLLOWING QUESTIONS:
I Want To Stop The HURTFUL MEMORIES: Yes No
I Want To Stop The SADNESS: Yes No
I Want To Stop The DEPRESSION: Yes No
I Want to Stop The ANGER: Yes No
I Want to Stop The FEAR/AFRAID/SCARED: Yes No
I Want to Stop The ANXIETY: Yes No
I Want to Stop The NERVOUSNESS: Yes No
I Want to Stop The JEALOUSY: Yes No
I Want to Stop FEELING GUILTY: Yes No
I Want to Stop The GRIEVING: Yes No
I Want to Stop THINKING ABOUT HIM/HER: Yes No
I Want To STOP SMOKING: Yes No
I Want To STOP CHEWING TOBACCO: Yes No
I Want To LOSE WEIGHT: Yes No
I Want to Stop My SUGAR ADDICTION: Yes No
I Want to Stop The DRINKING ALCOHOL: Yes No
I Want to Stop My DRUG PROBLEM: Yes No
I Want More SELF CONFIDENCE: Yes No
I Want to Stop The OBSESSIVE COMPULSIVE BEHAVIOR: Yes No
I Want A Better SEX LIFE: Yes No
I Want to SLEEP BETTER: Yes No
I Want Less PHYSICAL PAIN: Yes No
I Want Less EMOTIONAL PAIN: Yes No
I Want Less STRESS: Yes No
I Have An UNHAPPY RELATIONSHIP: Yes No
I Think of or have ATTEMPTED SUICIDE: Yes No
I Have Suffered ABUSE: Yes No
I Don't TRUST OTHERS: Yes No

ADDITIONAL COMMENTS
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How Did You Hear About Us?:
Is There A Good Time To Call You?
Your Time Zone Is:

The purpose of this form has been to briefly assess your needs. I will call you so we can will determine your needs. If you only need one session then that's what we'll do. On your first visit with me I will also do a mini-hypnosis-session for you.

I want to talk with you as soon as possible so I can help you achieve what you want so please be certain I have a phone number where you can be easily reached.

Thank you, and I really look forward to improving your life as I have done with thousands before you.

Dr. Leo Gagnon