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Email
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Name
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Year of birth
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Gender identification
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Address (City/Town/Province or State)
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Phone (needed as a backup for online sessions, or as emergency contact for in-person sessions)
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Children (ages)
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Occupation
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How did you hear about Quantum Healing Hypnosis (QHHT, BQH, etc)?
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How did you find / hear about me?
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QHHT Official directory
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Holistic Healing Fair
Group Regression
Other:
What is the main reason you are seeking a Quantum Healing Session?
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What are you doing, feeling, thinking or saying to yourself that you would like to change?
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Have you experienced Hypnosis in the past? If so, what was the outcome?
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