Client Intake Form
Year of birth
Prefer not to say
Address (City/Town/Province or State)
Phone (needed as a backup for online sessions, or as emergency contact for in-person sessions)
Single, separated, widowed or divorced
Married or common-law
How did you hear about Quantum Healing Hypnosis (QHHT, BQH, etc)?
How did you find / hear about me?
QHHT Official directory
Word of mouth
What is the main reason you are seeking a Quantum Healing Session?
What are you doing, feeling, thinking or saying to yourself that you would like to change?
Have you experienced Hypnosis in the past? If so, what was the outcome?
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