Schedule an Appointment or Request Information

Make an Appointment            Request Information

• Please fill in the information below so I will know how to contact you. 
• Appointment date and time is subject to the therapist schedule.
• Allow 24 hours or more from the submission of this form when scheduling an appointment date and time.
• If you are not contacted within 24 hours of submission of this form, please call or e-mail me.

bkindel@earthlink.net or 713-822-8560

Hypnosis

Name

Address

City State Zip

Work Phone

Cell Phone

Home Phone

e Mail address

Appointment Information:

    Date Requesting

    Time Requesting

    Length of Session None 30 minutes 45 minutes 1 Hour 1 1/2 Hours 2 Hours

    Hypnosis Subject

    Method of Payment Cash Check Visa MasterCard I will contact you for Credit Card Information.

    Additional Information:

Please print and complete the forms provided before arriving at the office.

Important: Hypnosis sessions are not intended as a replacement for appropriate medical care.