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Name *

First

Last

Date of birth *

Sex M/F Other *

Session Date and Time *

Address *

City *

State *

Zip *

Phone *

Email *

Marital status *

Children *

Employment *

Title/Duties *

How did you hear about Quantum Healing Methods? *

What is the Main Reason you are seeking a QHM Session? *

What are you doing, feeling, thinking or saying to yourself about which you’d like to change? *

Have you experienced Hypnosis in the past? If so, what was the outcome? *

Responsibilities and Liability Release *

• I agree and give my permission

1. I am willing to be guided through relaxation, visual imagery, hypnosis, and/or stress reduction techniques. I
am aware these modalities are non-medical in nature and it is my responsibility to consult my regular doctor
about any changes in my condition or changes in my medication.
2. I understand the above modalities are not substitutes for regular medical care and I have been advised to
consult my regular medical doctor or health-care practitioner for treatment of any old, new or existing medical
conditions.
3. I understand that change is my own and complete responsibility. I understand that ALL HEALING IS SELF
HEALING and that Devialini Agheda-De Souza is only a “facilitator” in the process of helping me to solve my own
problem(s). 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.
4. I understand I may be assigned “homework” or be asked to make changes to my life by my higher self in
regard to complete or solidify any healing or changes begun in our session today. I understand that this
information and advice for change comes not from the BQH facilitator, but from my own higher being.
5. I understand that my facilitator may elect NOT to proceed with the session if she/he feels it is not in their or
your best interest to do so. My Facilitator is NOT liable for travel costs (airline, hotel, etc.) associated with
declining a session.
6. I understand that our session will be digitally recorded for my later use. I also 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.

7. I agree to full release and hold harmless Devialini Agheda-De Souza and Cosmic Connections from against any and all claims or liability
of any nature arising out of, or in connection with, my sessions.

Special Use of Information : *

• Special Use of Information:

I understand that my name and personal information will be kept completely confidential.
I understand that I may share my recording and information in the future in any way that I am personally
comfortable.
I understand that often in BQH sessions, universal information is provided through the client to benefit all of
humanity. I agree to allow Devialini Agheda-De Souza and Cosmic Connections to share this information and any accompanying story
summary either in audio or video or in written form in blogs or books as long as my identity, name and all
relevant personal details are omitted or changed.

Client with full name and Signature *

Date *

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