The marked fields * are required

Full Name*:

Current age*:
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Which modality are you interested in?*:
QHHTIntegral Hipnotherapy

Why would you like to have this session?*:

Do you suffer from or have you been diagnosed with any psychiatric condition?*:

 No  Yes

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Do you suffer from any sleep disorder?*:

 No  Yes

Please provide more details

Do you suffer from any addiction?*:

 No  Yes

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Do you take any psychiatric prescription medication?*:

 No  Yes

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How did you find about about me?*:

Comments, questions or any detail you deem important for me to know:

Phone*:

Email*:

 For QHHT: I agree to pay the amount of $6000 MXN pesos for the session for its entirety, not per hour. To schedule, a non-refundable deposit of $1000 MXN pesos is required. This deposit is only transferable 1 time and only to another date not exceeding 30 days from the original date, depending on availability.*

 For Integral Hypnotherapy: I agree to pay for each session the amount established during our preliminary video consultation.*

 I only provided truthful answers*

 I have read and accept the privacy policy*