Quantum Healing Hypnosis Session Intake

Email*

Phone Number*

Date of Birth*

City and State where you live*

Occupation*

Relationship Status*

Partner Name

Partner Occupation

Children's Names and Ages

Please describe your Trauma

Do you use food, alcohol, or drugs to relieve tension? If so, what specifically do you use and how often?*

If this does not apply to you, enter 'N/A'

Please describe your current state of health.*

Have you ever been in counseling or psychotherapy? If so, how long, why did you seek therapy and what were your results?*

Are there any issues, problems, blocks you're currently dealing with you feel is karmic?*

Do you experience any phobias or "irrational" fears currently that have no ties to this lifetime? What do you fear?*

What would you say is your main concern at this time?*

Have you ever been in hypnosis?*

Briefly, why have you booked a session and what do you hope to achieve?*

What would you like to have answers to or resolve during your session? It could be an annoying pattern, clarity on a relationship, or anything in between! *

Is there anything specific you're wanting from your session? Keep in mind, we're going into the infinite! That means all information is possible. Are you missing a skill in this lifetime? Confidence? Or an experience you'd really like to have - what are you WANTING more of in this lifetime?*

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Quantum Healing Hypnosis Intake Form