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Addiction Release Application Form

For best results, Fiona will customize your script and session to address your own specific needs, origins and reasons why/why not. The more detail you can give us in the following section the easier and more effective your session will be.

Your application must be received in full before your session will be confirmed. Once we receive your application you will be emailed your invoice and link to schedule your 90Min Hypnotherapy Sessions. 

For best results we recommend sessions take place in person in Fremantle Western Australia, although sessions can also be completed over the zoom as required.

Click the button below to start.

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Question 1 of 18

Full Name

Question 2 of 18

Email Address (to match your answers with your session booking request)

Question 3 of 18

What Addiction are you here to release? (remember you can only release 1 addiction per session)

A

Smoking

B

Vaping

C

Food

D

Alcohol

E

S*x / pron

F

Illicit Drugs

G

Pharmaceutical Drugs

H

Gambling

I

Other

Question 4 of 18

How long have you had this addiction?

Question 5 of 18

How is it a problem for you now? (eg affecting my job, health, relationships)

Question 6 of 18

Why do you want to quit now?

Question 7 of 18

What was the main reason you started your addiction?

(Select all that apply)
A

Rebellion

B

Boredom

C

Peer Pressure

D

To Fit In

E

To Have control over something

F

Curiosity / Experimentation

G

It was cool

H

Distraction / Escapism from emotional pain

I

Feel Better

J

To Relax

K

Other

Question 8 of 18

Why did you Start your addiction? (please add more detail to extend your previous selections)

Question 9 of 18

What was the average weekly cost of your addiction when you first started?

Question 10 of 18

When / Where do you do your addiction? List as many habit places and triggers as possible eg. immediately when I wake up, only with food, only with friends, on a break

Question 11 of 18

What is the average weekly cost of your addiction now?

Question 12 of 18

What have you tried before to quit this addiction?

(Select all that apply)
A

Willpower

B

Counselling / Psych Therapy

C

Hypnosis

D

Cold Turkey

E

Pharmaceutical Aids eg niccorette

F

Formal Rehab

G

Support Groups

H

Other

Question 13 of 18

If you have previously tried something else to quit this addiction, please extend your answer to include what, when and why you think it didn't work or it did but you started again? If you haven't attempted to quit this addiction before just write n/a

Question 14 of 18

What potential downsides do you see of quitting? eg no longer fit in with friends, not sure what to do with your hands, lack of confidence in social situations without dutch courage

Question 15 of 18

Who is on your support team to succeed?

Question 16 of 18

How will your life be different when you have successfully released your addiction? What areas of your life are you expecting/hoping to see the greatest impact? 

Question 17 of 18

Why are you choosing Hypnotherapy to assist you to release your addiction now?

Question 18 of 18

Contact number (we will be in touch to discuss your application and confirm your session)

Confirm and Submit