COSMIC LIGHT
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QHHT Healing Session
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Home Euthanasia
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QHHT consent form
*
Indicates required field
Name
*
First
Last
Phone Number
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
1. I understand the service being offered is intended for my own self-healing and self-exploration through deep relaxation
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Yes, I understand and accept
I do not understand and do not consent
2. I understand that I am not receiving a service from a licensed psychologist or hypnotherapist, and do not intend to receive diagnosis, treatment or cure for any physical or mental illness or disease
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Yes, I understand and accept
I do not agree to receive this service
3. I have been informed about what to expect regarding the service I will be receiving and do not hold Cosmic Light or the QHHT practitioner responsible for any unexpected or unanticipated emotions experienced during or after the session.
*
Yes, I understand and accept
No, I do not accept
4. I understand the location of the service will be in Plymouth, Minnesota, and I will need my own transportation to my session. I understand the session will take 4-5 hours and I will be available for the entire session.
*
Yes, I understand and accept
No, I do not accept
Option 3
Client Signature
*
Today's date
*
Submit
home
Schedule an appointment
QHHT Healing Session
Contact us | Patient Form
Home Euthanasia
Hospice consultation
About Dr. Curtis
Fees
Grief Support