Brookside Center for Counseling and Hypnotherapy

20 Chestnut St., Suite 15N, Exeter, New Hampshire 03833

Phone/Fax (603) 778-9955

Print Order Form

Print the form below and mail it with your check or money order made out to Maurice Kouguell. (Note: Money Order payments will ship immediately. Personal checks will ship when check clears. All prices include shipping and handling within the US and Canada. All other countries add $5.00 US per item. Please print or type form.)

Name: ____________________________________________

Address: __________________________________________

City/State/Zip: ______________________________________

Country: __________________________________________

Phone/Email:  ______________________________ (in case there's a problem with your order)

_______1. DAPTHä (@ $47.50)

_______2. Human Figure Drawings (@ $36.00)

_______3. Dealing With The Unexpected (@ $54.00)

_______4. Be Spiraled Hypnosis Kit (@ $10.00)

_______5. Hypnosis Is My Bag Tote Bag (@ $20.00)

_______6. My Father's Words: Let the Houses be the Witnesses (@ 35.00)

Total: ______________

Comments: ________________________________________________________

Add me to your mailing list? _______yes _______no