Quantum Journey Questionnaire

Name*

First NameLast Name

Email*

example@example.com

Where do you live*

CityState

Why are you interested in a session with me? Can choose more than one*

Have you ever had any energetic work done on you before?*

YesNoI can't remember

If yes, what type/types?

Are you currently under the care of a physician?*

YesNo

If yes, for what reason?*

If prefer not to answer, state above

Are you taking any medications? Include any prescription drugs, over-the-counter medication, birth control pill etc..*

YesNo

Do you drink alcohol regularly?*

YesNo

Do you use recreational drugs?*

YesNo

Thanks for taking the time to complete this questionnnaire, I will contact you soon in the next day or two.