Vancouver Hypnotherapy - Rob Hadley MH., CHt. 778 772 5821

This form gives me some basic information about your alcohol issues. All information is treated confidentially.

Name: *

Phone Number: *

Email Address:

Date of Birth

mm/dd/yyyy

Gender

		Male
		Female

We're going to need some information about the scale of the problem. Try to answer the questions as honestly and accurately as you can.
Don't be worried by the answers. We need to know where we are now, before we can straighten this thing out.

Do you consider yourself a binge drinker? If so, how does this usually play out?

Do you drink every day? If so, how much (and what)? How much do you think you spend on alcohol a week?

Are you living with your partner?

Do you have children under 16?

Have people annoyed you by criticizing your drinking?

Have you ever felt guilty or bad about drinking?

Have you ever had a drink first thing in the morning to steady
your nerves or to get rid of a hangover?

Has your work ever been negatively affected by alcohol

If you are ready to do something about your consumption you will want to act before you
change your mind. Your commitment to this process is essential.

Please list three possible appointment times that work for you over the next 14 days.
I will try to accommodate these times if possible.

My rates for work on alcohol issues are $150 an hour. My office is located at Suite 400, 601 West Broadway, Vancouver.

Would you be prepared to pay a $50 premium to get in within 48 hours?

* = Input is required