Request for Coaching Consultation

Please complete this confidential profile and submit it us as soon as possible. It is important that we receive your completed form at least 24 hours prior to your scheduled consultation.

Please submit your completed form by hitting the "Send Information Now" button at the bottom of the form. In order to protect your privacy, DO NOT EMAIL THIS FORM. Submit your information by hitting the "Send Information Now" button once. You can also fax your form directly to: 800-497-6614. Either way, we recommend that you print out a copy of your completed form for your records.

Client Name
Name of Parent(s) or Guardian(s) (req'd if Client is under 18)
Primary Email Address
Home phone
Cell phone
Work phone
Address 1
Address 2
City
State
Zip
Country
Fax

Client Age
Client Date of Birth

Please provide a brief description of the goals of receiving coaching:
Please provide a brief description of the current struggle(s) that the Client is experiencing.

Please select (check) all that apply to the client's desire for coaching:
	Life Coaching	Spiritual Coaching
	Success/Business Coaching	Career/Employment Coaching
	Dating Coaching	Relationship Coaching
	Physical/Exercise Coaching	Competition Coaching

Please describe any previous experiences with Coaching:

Please describe any behavior or emotional issues that you feel might be relevant:

In your own words, please describe any significant emotional events during the most recent 3 years:
Please include any additional information which you believe may be relevant to the current struggle(s):

Please describe as clearly as possible the results that you (the client) would like to achieve. What are your goals/outcomes?
How did you hear about us?

Thank you for completing your information profile. Please take a moment to review your answers and add any information that you feel is relevant to achieving your desired results.

About Michael Stevenson MNLP, MTT, MHt

Michael is a trainer, coach, clinical hypnotherapist and Reiki Master with impressive credentials and experience. He is the author of the best selling book, Learn Hypnosis... Now!, which teaches people who have never used hypnosis to hypnotize themselves and others in just a few hours. He has hypnotized tens of thousands of people around the world in his decade-long career and is considered one of the world's foremost experts on the subjects of NLP and hypnosis. Michael's clients lovingly refer to him as the Orange County Hypnotist, yet his work is known world-wide. You can read more about Michael at his bio page and can contact him directly here.

Michael's Credentials

Author of the Best Selling Book Learn Hypnosis... Now!
Author of the Book UnStuck: The Owner's Manual for Success
Author of the Book Becoming a Hypnotic Influence Ninja
Author of the Book Tapping Into Wealth with EFT (Coming in 2011)
Certified NLP Master Practitioner and NLP Master Coach
Certified Master Trainer of Neuro-Linguistic Programming
Certified Master Practitioner of TIME Techniques™
Certified Master Trainer of TIME Techniques™
Certified Master Hypnotherapist
Certified Master Trainer of Hypnotherapy
Certified Master Success Coach
Certified Neuro-Linguistic Master Learning Specialist
Certified Neuro-Linguistic Learning Specialist Trainer
Certified in Advanced Clinical Hypnotherapy from AIH
Certified in Advanced Parts Therapy
Certified Reiki Master/Trainer (Usui Shiki Ryoho Method)
Ordained Minister with Universal Life Church Monestery
Board Certification by the International Board of Clinical Practitioners
Board Certification by the Int'l Association of Counselors & Therapists
Board Certification by the Int'l Medical & Dental Hypnotherapy Ass'n
Board Certification by the International Hypnosis Federation
Board Certification by the National Guild of Hypnotists
Board Certification by the American Board of Neuro-Linguistic Learning
The Transform Destiny Company is also certified as an approved training institute by IBCP, IHF, ABNLL, and NLC.

Contact us today to schedule your personal breakthrough session, or to sign up for one of our upcoming live seminars. Call 800-497-6614 toll-free, or 714-408-4281 direct.

NLP, Hypnosis and Reiki

Request for Coaching Consultation

About Michael Stevenson MNLP, MTT, MHt

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