Quantum Regression Agreement Form

Name *

Email *

Select your preferred session type *

Quantum Healing Hypnosis Technique (QHHT) - in person
Beyond Quantum Healing (BQH) - online or in person
Angelic Universal Regression Alchemy (AURA) Hypnosis Healing Technique - online or in person

I have been hypnotized before *

Yes
No
Unsuccessfully (please clarify below)

My main reasons for wanting to be hypnotized are... *

NOTE: Provide general comments at the very least but any information will be useful in preparing for the session appropriately.

I am of legal age and voluntarily wish to participate in this Quantum Regression session with Ali. I am willing to be guided through relaxation, visual imagery, hypnosis, and/or stress reduction techniques. I understand the above modalities are not substitutes for regular medical care and I understand that Ali is not a doctor, nor does she hold a degree in Psychiatry or Medicine. She can neither diagnose nor treat any type of physical or mental disorder nor is hypnosis a substitute for regular medical care. *

Agree
Agree; This session is for my child 10 years or older and I am the legal guardian
Agree; I will be acting as a surrogate for my child who is under 10 years of age and I am the legal guardian

I understand that I am not a patient, but a co-creator in my Quantum Regression experience. I understand that change is my own and complete responsibility and that ALL HEALING IS SELF HEALING. I understand that any subsequent self-healing involves self-care physically, mentally, emotionally and spiritually which may take time. I understand I may be assigned “homework” or be asked to make changes to my life by my "Higher Self" to complete or solidify any healing or changes begun in the session today. I understand that this information and advice for change comes not from the facilitator, but from my own higher being. *

Agree
Agree; This session is for my child 10 years or older and I am the legal guardian
Agree; I will be acting as a surrogate for my child who is under 10 years of age and I am the legal guardian

I understand that all information I give for the purpose of the session will be held as strictly confidential and that any misleading information I provide or information that is purposely omitted may skew the session. It is my responsibility to be open and honest, provide accurate feedback, and be forthcoming with details and information that may help me achieve my outcomes. *

Agree
Agree; This session is for my child 10 years or older and I am the legal guardian
Agree; I will be acting as a surrogate for my child who is under 10 years of age and I am the legal guardian

I understand that in these types of metaphysical sessions, the energy in the room can affect the equipment and recording resulting in static or blank recordings. (This is quite rare, but it does happen) I understand that I will be given a copy of my recorded session and it is my responsibility to save and store my session safely. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Soul Healing Essentials from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my sessions. I understand that sessions performed over the web have inherent technical issues that may result in interruptions or disconnections that may or may not be able to be resolved that may result in an aborted session. I understand that rescheduling an aborted session is at the sole discretion of the facilitator. *

Agree
Agree; This session is for my child 10 years or older and I am the legal guardian
Agree; I will be acting as a surrogate for my child who is under 10 years of age and I am the legal guardian

I understand that my name and personal information will be kept completely confidential and I may share my recording and information in the future in any way that I am personally comfortable. I understand that often in intuitive or Quantum Regression sessions, universal information is provided through the client to benefit all of humanity. I agree to allow Soul Healing Essentials to share this information and any accompanying story summary either on video or in written form in blogs or books as long as my name and all personal/relevant details are omitted or changed to protect my identity. *

Agree

I understand that Soul Healing Essentials may elect NOT to proceed with the session if she feels it is not in her or in her client’s best interest to do so. Soul Healing Essentials takes NO FEE for a declined session and is NOT liable for travel costs (airline, hotel, etc.) associated with declining a session. *

Agree

I agree and understand that this item is non-refundable once purchased. *

Agree

Additional information

NOTE: Provide any additional information you may feel is relevant to the booking of this session including any/all prescription medications used for anxiety, depression, seizures or pain. Please advise if you have ever been treated for schizophrenia, MPD, psychosis or PTSD.