The information collected from this online form, will be used to create your "I am NOW a non-smoker" hypnosis recording.  This is the recording that you will use on your "QUIT DAY".  

Once this form is received by us, you will receive your custom-tailored recording within 5 to 7 business days. Please complete this as soon as possible. 
Thank you.

STEP # 1, 

Download/Print this
Identify your triggers 001.pdf Identify your triggers 001.pdf
Size : 252.546 Kb
Type : pdf

   STEP # 2,
Complete the worksheet

STEP # 3, 

Transfer final worksheet info
to the online form below.

STEP # 4, 

Complete the "five senses plus"
exercise found on the same form.
Then submit the form.

If you have questions or need assistance of any kind regarding the completion of this form, feel free to email or call.


*** The following information is required in order to custom produce your STOP SMOKING hypnosis recording "I am NOW a non-smoker". Please complete and submit A.S.A.P. Thank you.




FIVE SENSES PLUS EXERCISES *****************NOW IMAGINE, MAKE BELIEVE, PRETEND .... that 6 months has gone by. You've been smoke free for 6 months. What will you sense as PROOF that you are a non-smoker.

SIGHTS (check what applies)

SOUNDS (check what applies)

SMELLS (check what applies)

TASTES (check what applies)

TOUCH (check what applies)

FEELINGS (check what applies)