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Quantum Healing Hypnosis Session Request
1
Name
*
This field is required.
First Name
Last Name
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2
Email
*
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example@example.com
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3
Phone Number
Area Code
Phone Number
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4
Are you seeking an in-person or online session?
*
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Inquiry only. Payment is not accepted through this form. In person sessions run ~4 hours. Online sessions run ~3-4 hours.
In-person session ($350)
Online session ($350)
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5
Date requested
Please enter a date that works for you. We will work together to schedule a date and time that fits both our schedules.
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Date
Year
Month
Day
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6
Time requested
Time slots begin at 12 PM or 1 PM EST. In-person sessions usually run ~4 hours. Online sessions run ~3-4 hours.
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7
For Online session requesters only, what time zone are you located in?
Please write down your City, State, Country, and time zone (i.e. PST, MST, EST, GMT, etc.)
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8
Have you had any form of Hypnosis before? Or any other experience with energy healing work?
Yes
No
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9
What is your main reason for seeking a Quantum Hypnosis session?
*
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10
Do you have any medical conditions? If so, please list them here and how you are treating them.
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11
What is your birth date?
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Year
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Day
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12
Where are you located / traveling from?
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13
Are you able to travel to Greenpoint, Brooklyn for your in-person session?
*
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In-person sessions are located close to the Greenpoint Ave G train.
Yes
No
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14
I'm curious, how did you find me?
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15
Thank you for your time. Jessica will be in touch shortly via email.
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