Practitioner Information

Please take a few moments to answer the following questions. They will help us make appropriate referrals to those who may be seeking your services. Although this questionnaire is designed for NLP, Hypnosis, and Personal Development Coaches - feel free to complete it if you practice some other holistic modality. (Be sure to use the specializations/other information section to let us know what you do.)

Please provide the following contact information:

First Name Last Name

Business Name (if applicable)

* Phoenix Services will not share your street or mailing address with any outside individual or agency, nor will it be published on the web. It is required field for our administrative use.

Address Line 1

Address Line 2 (if needed)

City

State/Province

Zip/Postal Code

Country

(Area Code) Work Phone ()

FAX

E-mail

Web Address
Which of the following apply:

Hypnotherapist
NLP Practitioner
Personal Development Coach
How much experience do you have? :

I've been in practice since
Specializations or other additional information:

Address Line 1
Address Line 2 (if needed)
City
State/Province
Zip/Postal Code
Country
(Area Code) Work Phone	()
FAX
E-mail
Web Address

First Name	Last Name
Business Name (if applicable)

Practitioner Information

Michael WatsonCopyright © 2000 Phoenix Services for Personal Development. All rights reserved. Revised: September 27, 2007

Michael Watson
Copyright © 2000 Phoenix Services for Personal Development. All rights reserved.
Revised: September 27, 2007