Confidential Client Appointment Form This Form helps to me help you Your Email (required) Subject or help needed Appointment Date if set: Best Contact Phone: HomeWorkMobile Date of Birth: Age: Marital Status: SingleMarriedDivorcedSeparated If Married, Spouse's Name: Children? YesNo. Sexual Orientation: StraightGayBi Do you follow or observe any religious or meditative practices? If so, please describe: SEE THIS โ Type it in here โ Call Glenn at 561 201-1838 to learn more about hypnosis.