Please highlight this Form, copy and paste it into an email. Then fill it
out and send to me at drknight AT hypnosisdepot DOTcom 

Name: 
__________________________________________________________________
Address: 
________________________________________________________________

____________________________Country___________postal or zip code:__________

Home/cell phone: [   ]__________________________Work phone: [   ]_____________

Date of birth:_____________                 Email:______________

Fax: [   ]_______________                  Today's date: ______________

Marital Status: (circle answer)  single; engaged; co-habiting; married; remarried; 
separated; divorced; widowed 

Name and age of spouse (or partner) 

and sisters and brothers:

Names and ages of children:

Time zone you live in:

[For NetHypnosis clients only] Person and phone number I should call 
in case of emergency:

                                     *   *   *

This form is designed to prompt you to begin thinking about your life in new
ways, and to give me therapeutically-relevant information about you. 
Whatever you write will be kept confidential. Answer each question with the
first uncensored thought that springs to mind. Write as much or as little as
you choose.

How did you hear about my services?

What is your main problem and when did it begin to bother you?

What do you specifically want to get out of therapy

From whom have you sought help for your problem(s)?

How is most of your free time occupied?

If employed, what kind of work do you do?

Does your current work satisfy you?     If not, in what ways are you
dissatisfied?

If you have hobbies, please describe them here:

What are your feelings towards animals?

If printing, circle any of the following words that apply to you. If sending by email, delete the words that do not
apply

headaches	       dizziness	         fainting spells
palpitations	       stomach troubles	         anxious
bowel problems	       fatigue	                 no appetite
angry	               take sedatives	         insomnia
nightmares	       feel panicky	         use alcohol
tension	               in conflict	         tremors
depressed	       suicidal ideas	         take drugs
unable to relax	       sexual problems	         allergies
dislike weekends       over ambitious	         shy
dislike vacations      feel inferior	         indecisive
can't make friends     poor memory	         home life bad
hopeful	               lonely	                 can't concentrate
use painkillers        fearful                   obsessive		
grateful	       perfectionist             sad
creative	       playful	                 can't have fun
sleep problems	       isolated                  compulsive
ashamed	               flexible	                 worthless
bored	               useless	                 deformed
life is empty	       a nobody           	 inadequate
stupid	               incompetent	         naive
guilty	               evil	                 horrible thoughts
intelligent	       morally wrong	         full of hate
cowardly	       unassertive	         aggressive
ugly	               unloved	                 confused
confident	       considerate	         unforgiving
can't keep a job       resentful	         sympathetic

Please list other problems or difficulties here:

What physical illnesses or symptoms do you have?

When was your last medical check-up?              
                                                                                         
List medications (and doses) you are taking:

Please list your hospitalizations for physical or mental illness:

What were the important mottos, themes, or messages you learned from your
family?

How have those messages affected your self-image and your behaviour ?

Describe your current relationship with your family of origin:

Describe any loss you've suffered (e.g., death of a loved one, bankruptcy, abortion):

Please complete the following with the first thoughts that pop into your 
mind:

I am a person who

All my life

Ever since I was a child

One thing I'm proud of is

It's hard for me to admit

One of the things I can't forgive

One of the things I feel guilty about

If I didn't have to worry about my image

One of the ways people hurt me

My mother was always

I wish my mother would have

Being a woman means

Being a man means

When I look in a mirror

My spiritual/religious beliefs

As a child my spiritual/religious beliefs

My father was always

I wish my father would have

If I weren't afraid to be myself, I might

One of the things I'm angry about

What I need and have never received from a woman

What I need and have never received from a man

The bad thing about growing up	

One of the ways I could help myself

My greatest accomplishment

A person who loves me would say I

I describe myself as

Someone who dislikes me would say I


Write about one or more dreams you've had at night, especially if you've 
had the same dream more than once:




Your signature verifies you understand

 "that the success of the treatment will be in direct proportion to my commitment

 to the end result."


Signature _________________________________________________

I am coming to my appointment at the Westside Medical Clinic
 (phone is 514-489-5753) at 4260 Girouard Avenue (corner Monkland) Suite 240, Montreal H4Y 3Z9.
 and will pay there, by cash (  ), by cheque (  ).

(The Clinic does not accept credit cards).

(  ) YES. I have read Dr Knight's 
"HYPNOSIS: 77 Answers
 to Questions I Wish You'd Stop Asking"

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
[NetHypnosis clients only] I am registering for NetHypnosis and sending $90 U.S. by:
(  ) PayPal to drknight AT hypnosisdepot DOT com
(  ) Money order to Dr Bryan Knight, Westside Medical Clinic
 (phone is 514-489-5753) at 4260 Girouard Avenue (corner Monkland) Suite 240, Montreal, QC, Canada H4Y 3Z9.