PLEASE TRY TO GIVE US ALL THE INFORMATION THAT YOU CAN.

Name

Email Address

Tell me about a habit that you would like to be free of?

How long has this been something you have thought about changing?

Give me three or four reasons, big or small, regarding why you want to change this?

On the plus side, if anything, what does this do for you?

Do you think you are addicted, or do you have a habit? What makes you say that?

Who is dearest to you? If there is more than one, that’s fine. Tell me about them?

Imagine, you have made the changes, you are completely free of that habit? How do you feel?