Client Intake Form
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Email *
Name *
Year of birth
Gender identification
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Address (City/Town/Province or State)
Phone (needed as a backup for online sessions, or as emergency contact for in-person sessions) *
Marital status
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Children (ages)
How did you hear about Quantum Healing Hypnosis (QHHT, BQH, etc)?
How did you find / hear about me?
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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