Pain & Migraine Registration

Date*
MM slash DD slash YYYY
Choose How You Want To Do Your Session. Via Phone Coaching Or Zoom:
- Phone Coaching
- Zoom
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Office Consultation Fee*
Price:
WE DO NOT SEE OR RETAIN CREDIT CARD INFORMATION.
Credit Card*
Card Details
Cardholder Name
PLEASE CALL OR TEXT FOR YOUR APPOINTMENT WHEN YOU COMPLETE THIS REGISTRATION FORM! (334)233-5610

WEIGHT LOSS

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PAIN & MIGRAINE

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STOP SMOKING

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ANXIETY & DEPRESSION

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ALCOHOL & DRUGS

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GAMBLING

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Stop Smoking Registration

Date*
MM slash DD slash YYYY
Choose How You Want To Do Your Session. Via Phone Coaching or Zoom:
- Phone Coaching
- Zoom
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Initial Consultation Fee*
Price:
WE DO NOT SEE OR RETAIN CREDIT CARD INFORMATION!
Credit Card*
Card Details
Cardholder Name
PLEASE CALL OR TEXT FOR YOUR APPOINTMENT WHEN YOU COMPLETE THIS REGISTRATION FORM! (334)233-5610

Private Weight Loss

Date*
MM slash DD slash YYYY
Choose How You Want To Do Your Session. Via Phone Coaching Or Zoom:
- Phone Coaching
- Zoom
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Initial Consultation Fee*
Price:
WE DO NOT SEE OR RETAIN CREDIT CARD INFORMATION!
Credit Card*
Card Details
Cardholder Name
PLEASE CALL OR TEXT FOR YOUR APPOINTMENT WHEN YOU COMPLETE THIS REGISTRATION FORM! (334)233-5610

Special Offer: Weight Loss Recordings (1) $19.95 (2) $35.00

Click Here to Order

General Registration

Date*
MM slash DD slash YYYY
Choose How You Want To Do Your Session. Via Phone Coaching Or Zoom:*
- Phone Coaching
- Zoom
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Initial Consultation Fee*
Price:
WE DO NOT SEE OR RETAIN CREDIT CARD INFORMATION!
Credit Card*
Card Details
Cardholder Name
PLEASE CALL OR TEXT FOR YOUR APPOINTMENT WHEN YOU COMPLETE THIS REGISTRATION FORM! (334)233-5610

Gambling Registration

You will be contacted for an appointment when we receive your completed form.

Date*
MM slash DD slash YYYY
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Office Consultation Fee*
Price:
Once you make this payment complete the second half of the form that asks details about your lifestyle problem. All information is confidential and only seen by Dr. Smith.
Credit Card*
WE DO NOT SEE OR RETAIN CREDIT CARD INFORMATION!

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Alcohol & Drugs Registration

You will be contacted for an appointment when we receive your completed form.

Date*
MM slash DD slash YYYY
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Office Consultation Fee*
Price:
Once you make this payment complete the second half of the form that asks details about your lifestyle problem. All information is confidential and only seen by Dr. Smith.
Credit Card*
WE DO NOT SEE OR RETAIN CREDIT CARD INFORMATION!

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Anxiety & Depression Registration

You will be contacted for an appointment when we receive your completed form.

Date*
MM slash DD slash YYYY
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Consultation Fee*
Price:
Once you make this payment complete the second half of the form that asks details about your lifestyle problem. All information is confidential and only seen by Dr. Smith.
Credit Card*
Card Details
Cardholder Name

WE DO NOT SEE OR RETAIN CREDIT CARD INFORMATION!

Pain & Migraine Registration

You will be contacted for an appointment when we receive your completed form.

Date*
MM slash DD slash YYYY
Choose How You Want To Do Your Session. Via Phone Coaching Or Zoom:
- Phone Coaching
- Zoom
First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Office Consultation Fee*
Price:
WE DO NOT SEE OR RETAIN CREDIT CARD INFORMATION.
Credit Card*
Card Details
Cardholder Name
PLEASE CALL OR TEXT FOR YOUR APPOINTMENT WHEN YOU COMPLETE THIS REGISTRATION FORM! (334)233-5610

Free Weight Loss Registration Form

Click here to complete the Registration!

Free Stop Smoking Registration Form

Click here to complete the Registration!

Free General Registration Form

Click here to complete the Registration!

Trim-Style Weight Loss Recordings

These are Weight Loss Meditation Recordings for behavioral and emotional change that gets to the source of unhealthy habits. These recordings include psychological techniques to eliminate fattening foods, cravings, reduce portions, snacking, as well as to reduce stress and emotional eating. Consistent listening and applying the weight loss strategies will increase the desire for healthy foods, water and physical activity. They are extremely relaxing and produce an enduring state of calmness. Choose the recording(s) below that address your needs for creating weight loss habits. DO NOT LISTEN & DRIVE!

First Name*
Last Name*
Email*
Phone*
Weekly Weight Loss Recordings*
- Receive ALL (10) Weight Loss Recordings
- Portion Control & Snacking
- Eliminate Craving for Sugar & Salt
- Increase Exercise Mortivation
- Stop Stress Eating
- Hunger Control. Know when to stop
- Increase Self-Esteem Reduce Weight
- Stop Sabotaging Weight Loss
- Relapse Prevention Stay Focused
- Stop Emotional Eating
- Increase Metabolism Subconsciously
These (10) weight loss recordings are $19.95 each a $199.50 value. However purchase all 10 now and receive them for $149.50 a $50 savings on these effective weight loss and stress control recordings.
Select the Offer*
- Receive (10) Weight Loss Recordings. Purchase NOW & get all (10) for $149.50
- 1 Recording - $19.95
- 2 Recordings - $35.00
- 3 Recordings - $54.95
- 4 Recordings - $74.90
- 5 Recordings - $94.85
- 6 Recordings - $114.80
- 7 Recordings - $134.75
- 8 Recordings - $154.70
- 9 Recordings - $174.65
- 10 Recordings - $194.60
Total
$0.00
Credit Card*
WE DO NOT RETAIN CREDIT CARD INFORMATION!

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Pain Relief and Relaxation Recordings

There are (2) Pain Control Recordings that reinforce private and group pain management sessions. They produce deep relaxation, restorative sleep and include psychological pain relief techniques. They are not intended to treat medical conditions. Do not stop taking prescribed medication without your doctors advice. Do not listen and drive. Your recordings will be delivered via email. Receive (1) $19.95 or (2) $35.00.

First Name*
Last Name*
Email*
Phone*
Select the Offer*
- 1 Recording - $19.95
- 2 Recordings - $35.00
Total
$0.00
Credit Card*
WE DO NOT RETAIN CREDIT CARD INFORMATION!

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Corona Anxiety Stress & Depression Release

There are more than (8) different recordings that are intended to reinforce private and group teletherapy sessions. They produce deep relaxation, restorative sleep, supports the immune system and include psychological techniques for positive change. Do not stop taking prescribed medication or listen when driving. Your recording will be delivered via email. Receive (1) $19.95 or (2) $35.00.

First Name*
Last Name*
Email*
Phone*
Select the Offer*
- 1 Recording - $19.95
- 2 Recordings - $35.00
Total
$0.00
Credit Card*
WE DO NOT RETAIN CREDIT CARD INFORMATION!

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Short Therapy Session

Register & Pay $35 for Office Consultation

First Name*
Last Name*
DOB*
MM slash DD slash YYYY
Age*
Marital Status*
Occupation*
Email*
Phone*
Office Consultation Fee*
Price:
Once you make this payment complete the second half of the form that asks details about your lifestyle problem. All information is confidential and only seen by Dr. Smith.
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

This is strictly confidential! You will receive absolutely FREE a Behavioral Weight Loss Session in the comfort of your home.

Date*
Name*
Email*
Mobile Phone*
Please provide the name of the person who referred you?
You receive FREE weight loss recording when you join our weekly behavioral sessions. It is a $19.95 value.
Attending with a group?*
- Yes
- No
What Group?
Please check your email for the date, time and tele-conference number to access the private weight loss session. (When you enter the tele-conference DO NOT Announce Your Name if you wish to remain anonymous.).

Request An Appointment

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- Initial Consultation $35 Click Here

Dr. Clinton W. Smith, Psy.D

Therapeutic Guided Meditation

For Assistance:

Call Us: (334)233-5610
Email Us: DrClintonWSmith@gmail.com

(334)377-4183