Custom Personalized CD Order Form
Romane will record a personalized hypnosis CD for you, (with an extra copy), for $300 (Canadian) plus tax.
Shipping is included. Sorry, no refunds.
Number of Children:
Education: Last grade completed:
Medical History: Please list any diseases, allergies, surgeries or medications:
Habits: Please check all that apply:
How good do you feel about yourself:
What would make you feel better?
Any current stress or worries?
Your General Health is?
Are you in physical discomfort?
If yes, please describe condition:
Present Problem (in your own words):
Why is it important for this change to occur?
Do other members of your family have the same problem?
Duration of problem:
Severity of problem:
Times when problem is most evident:
What have you done previously to try and solve the problem?
(A) Professional help:
(B) Medications taken:
(C) Other methods:
Results of these efforts:
Are you aware of any emotional problems or physical conditions that might account for your problem?
What would happen if you never achieved this goal?
Briefly describe a time in your life when you felt completely relaxed and happy:
Have you ever been hypnotised?
If yes, how?
Do you have any of Romane’s recordings?
If yes, which ones:
Why have your chosen hypnosis?
What do you know about hypnosis?
Is there anything that you have not yet told me, which you think I should really know?
Are there any specific thoughts you want Romane to give you during hypnosis while your mind is focused?
1. M.V.P. Ltd., Romane - does not offer any programs as a supplement to or replacement for any medical or
psychological services rendered for any mental, emotional or physical disorder.
2. M.V.P Ltd., Romane - cannot absolutely guarantee success. Results vary. Please use with physician’s support.