Registration
Your name in full:
Your answer
Occupation:
Your answer
Date of birth:
day, month, year
Your answer
Cell:
Your answer
Email:
Your answer
City and suburb:
Your answer
How did you hear about my services?
Do you have any of the following:
*If you are are currently taking medication please specify
Your answer
On average, how many hours of sleep to you have per night
Your answer
Please describe your diet on a routine day, including any snacks:
(Breakfast, tea/coffee breaks, lunch, supper)
Your answer
How often do you exercise to the point where you experience an increase in your heart rate and breathing?
Your answer
Are you in a relationship?
Your answer
If yes, does your relationship make you happy?
Your answer
Are there any stresses financially?
Your answer
Are you often indecisive?
Your answer
Have you ever been hypnotised before?
Your answer
Have you previously consulted any other professional about your concern?
(If Yes please specify)
Your answer
What is your present concern, and how would you like to feel?
Your answer
Package or Pay-As-You-Go?
Two hours are required for your first session. Select your preference from the list of packages below. Remember that hypnotherapy is not magic, it's training. Therefore, the more sessions you have, the easier it will be for you to make the changes you want, and the greater and more permanent those changes will be. Payment is by credit card or EFT, if you would like to pay cash please let me know prior to your treatment. I will email your receipt for your tax rebate, category "vocational stress therapy".

Please ensure that your package is paid in full before your first session.

Fees and Packages
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More info about the free hour you receive worth R400 every time you refer someone here: http://andy-wilding-hypnotherapy-cape-town.com/keep-calm-and-refer-a-friend/

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EFT:
Absa
Branch Code: 632005
Savings
Acc Number: 9090987859
Beneficiary: Andrew Wilding
Reference: Your Name

If you prefer to use your credit card via Payfast you can do so here: http://andy-wilding-hypnotherapy-cape-town.com/how-much-does-hypnosis-cost/

Please allow 24 hours for all cancellations or changes in scheduled appointments. Missing a scheduled appointment without prior cancellation may be charged at the current full rate.

Thank you. Please click "Submit" to return the registration form.
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