The journey starts within✨Quantum Healing Hypnosis Technique (QHHT) Client Intake Form Personal Information Name * First Name Last Name Birthdate * MM DD YYYY Phone * (###) ### #### Email * Emergency Contact * How did you hear about this session? * General Health & Well-being Do you have any medical conditions or physical limitations that might affect your session? * Yes No Are you currently on any medications? * Yes No Have you ever been diagnosed with a mental health condition (anxiety, depression, PTSD, etc.)? * Yes No Do you have any hearing impairments or difficulties relaxing for extended periods? * Yes No Spiritual & Personal Exploration Have you ever experienced hypnosis, guided meditation, or deep relaxation techniques? Yes No What are your main intentions for this QHHT session? * (Check all that apply) Physical Healing Emotional Healing Understanding Life Purpose Exploring past lives Connecting with higher self Gaining clarity on personal challenges Other Anything you'd like to share? * Consent & Agreement I understand that QHHT is not a substitute for medical or psychological treatment and that results may vary based on my own openness and subconscious mind. I acknowledge that I am voluntarily participating in this session and take full responsibility for my experience. I understand that the session may be recorded for my reference and that all information will remain confidential. I consent to this process with an open mind and heart. Digital Signature * First Name Last Name Date MM DD YYYY Recording & Release Agreement As part of my Quantum Healing Hypnosis Technique (QHHT) practice, I may record sessions for documentation, client reference, or educational purposes. Please review the options below and indicate your level of consent. Session Recording * I acknowledge that my session may be recorded for my personal use and reference. Yes No Sharing of Session Content * I understand that portions of my session may be shared for educational or promotional purposes. I consent to the following (check all that apply) My session may be shared publicly My session may be shared privately My voice may be used, but my name and personal details must remain anonymous I consent to only written transcripts or summaries being shared Edits & Anonymity * I understand that my session may be edited for clarity, length, or to remove personal details. I prefer that my session be shared with voice alterations for anonymity. Right to Revoke Consent I understand that I can change my mind at any time and request that my session be removed or no longer shared. To do so, I must submit a written request, and reasonable efforts will be made to remove the content promptly. Digital Signature * First Name Last Name Date MM DD YYYY Thank you!
