EDMONTON ADDICTIONS HYPNOTHERAPY & EXECUTIVE COACHING
ADDICTION RECOVERY & RELAPSE TREATMENT
OFFICE & ONLINE
St. Albert Medical Center (780) 418-1973
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CONSULTATION REQUEST
"A year from now you will wish you had started today." Karen Lamb

CONSULTATION REQUEST

Please note that all fields followed by an asterisk must be filled in.

First Name*

E-Mail Address*

City*

Best daytime telephone number/s*

Age*

Occupation*

Level of programming you have chosen.*

What services have you made use of in the past to address addictions?*

What is your number (1) reason for addressing addictions?*

How long have you been experiencing the current issue?*

	-2 years
	+2 years

Question/s?

Please choose one option*

	I am ready to schedule an initial consultation please call me as soon as possible
	I am not yet ready to schedule an initial consultation

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