Survey Form
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The Gallant Hypnotherapist's Information Survey

The purpose of this survey is to collect information from you to help us learn more about our guests who stopped by and paid us a visit. This information will not be sold, it will be confidential. If you wish to only answer the questions and not leave an address this is fine also,  thank you for taking you time to fill the questions out and submitting them.

This survey is divided into the following sections:

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information, and submit the form. You will receive a confirmation message from us shortly.

1. Have you ever been Hypnotized?
2. How long ago was your last hypnosis session? Last 3 months     
6 mos.-1 yr. ago     
1-2 years ago     
2-5 years ago      
5 or more years ago         
never 
3. Why did you see a Hypnotherapist?
4. Was it a positive Experience?
5. Would you like to see a Hypnotherapist?
6. Why would you like to see a Hypnotherapist? Please explain below, remember your answers will be kept totally confidential.
We would like to add you to our mailing list. This is not required, this is an option. Mr. Gallant will be sending out his latest newsletter within the next few months. If you wish to be informed please fill out the form below. Thank you.
Name
Address
City
State
Zip
E-Mail Address
Sex   Male  
Female   
Pre-Op TS   
Other
Age Under 18   
18-24   
25-35  
35-50   
50-65 
Over 65
Marital Status Single
Married
Divorced
Separated (Perm.)
Separated (Temp./Trial)
Living Together
Polyamorus Relationship
Alternative Lifestyle
Number of Children
Number of children who live with you
Number of other dependents
Any special problems with your children or dependents
Ethnic Background Caucasian   
African-American    
Asian    
American Indian
European Mix  
Hispanic      
Multi Racial            
Other
Income Level (annually)  Under $10,000   
$10,000-$25,000   
$25,000-$35,000
$35,000-$50,000        
$50,000-$75,000           
above $75,000
Years of Experience on the Internet Less then 1 year   
1-2 Years   
2-3 Years   
3-5 Years   
More than 5 Years

How stressful is?
List 1-10 the following items on level of stress. 1 being very relaxed and ok. 10 being time to pull out your hair. 

Work in General
Commuting to Work/Home   
Shopping
Making Dinner
Laundry  
Housework
Guests stopping by unannounced
Spouse  
Children
People borrowing your things
Meetings (clubs or otherwise)  
Work  
Banks  
Vacations
Sex
Smoking
Going Out to Dinner
How do you relax?

Which of these would you like to learn more about and get help with? Check as many as fit you and your needs.

Want to quit smoking Want to lose weight
Increasing Energy Need to change or modify a habit
Pain Relief (Requires Doctor's approval) Fear of the dark
Any other unwanted fears Fear of heights
Fear of closed spaces (claustrophobia) Fear of open spaces (agoraphobia)
Reduced Pain Natural Childbirth (Requires Doctor's approval) Painless Dentistry (Requires Dentist's approval)
Stress relief Help with relaxation
Increasing Self Confidence Self Hypnosis Training
Enhancing Creativity Improving Memory and/or Concentration
Help With Study Habits Improve Self Image
Becoming Healthier Becoming Happier
Relationship Issues Abundance Hypnosis
Life Transactions Increasing Motivation
Working with Dreams under Hypnosis Current Life Regressions
Past Life Regressions Find Lost or Misplaced Items 
Other:
Please enter any additional comments regarding our services. If you would like Mr. Gallant to contact you to set up an appointment, please include that and your phone number here. (All appointments are in the Vancouver/Portland area.)

Thank you for taking the time to answer the questions in our survey.

This is solely for research by Mr. Gallant, he wishes to know how best to serve his clients and you who were kind enough to stop by and visit us today. If you included your phone number above, or mentioned you might be interested in an appointment in the Vancouver, WA area, you will be contacted by either phone or e-mail. (Please state your preference.) Thank you for all your help on this survey.