Prepare Your Session

Please spend some time thinking about what you would like to accomplish during your QHHT session and the questions that you would like to address. When ready, fill out this form.

It would be advised to keep and bring a copy of the questions and I will make sure to forward you a copy of this form when I receive it.

All communications between myself and my clients are strictly confidential.

Name

First Name

Last Name

Address

City, State, Country

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Age

Gender

Health Concerns

Any Phobias or Allergies?

Have you ever been diagnosed with a mental disorder?

General Questions

Specific Events to Explore

How did you hear about me / QHHT?

What is your past experience with meditation, hypnosis, or other mind exploration techniques?

General consent and liability waiver

All sessions are done in a very safe space and the client's wellbeing is my ultimate focus. Sessions have always been 100% beneficial for my clients and there have never been any instances of any negative reactions from them. I only use this consent form as a safety liability waiver. Please write "I agree" and sign *your name* below if you agree to the following: I, *____*, understand that Erica Leeds does not guarantee healing and cannot predict or guarantee any particular outcome from a QHHT session. *____* releases Erica Leeds from, and assumes the risk of, and waives all liability caused by, and claims, demands, actions, and causes of actions whatsoever against Erica Leeds to any psychological or physical damage that may result from a QHHT session with Erica. *____* desires to hold harmless Erica Leeds and indemnify from all liabilities, claims, losses, judgments, suits, fines, penalties, demands, or expenses that may result from *____*'s participation in a QHHT session.

Erica may share non-personal clips or aspects of my session appropriately and anonymously with the QHHT community in order to enlighten and help other practitioners

Prepare Your Session

Book a session today!