Patient Intake Questionnaire

Please complete the form below so that we may accurately assess your needs

Thank you for taking the time to complete this questionnaire.


The information you submit in this form is kept absolutely private and confidential. It is for my eyes only. This intake questionnaire will help me to create a treatment plan specifically tailored to your individual needs. I appreciate you taking the time to fill out this form and I look forward to working with you.

Stop Smoking

Stop smoking in just one visit with almost no withdrawal symptoms with Dr. Eimer’s proven hypnosis method

Lose Weight

Achieve your weight loss goal and maintain it with self hypnosis and emotional self management

Control Chronic Pain

Gain control over chronic pain through Dr. Eimer’s hypnosis techniques and feel comfortable again

So Much More...

Let Dr. Eimer help you overcome phobias, anxiety, depression, limiting bad habits and much more.

I'm Here To Help

If you are interested in working together, send me an inquiry and I will get back to you promptly!

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