ࡱ> @ djbjb dde^ylDnnnnTB,nh'$  %''''''''''''',( *zS'"S'! !!!"%'!0%'!!n <Lnnlh'h'&+!&+!The Paperwork Please complete the following pages before emailing them to Cheryl Rodgers at the Quantum Techniques office at:  HYPERLINK "mailto:Cheryl@quantumtechniques.com" Cheryl@quantumtechniques.com. They will then be forwarded to your practitioner of choice. Please check with Cheryl to determine if your practitioner of choice is currently taking new clients. New Client Information Sheet Practitioner of Choice (Required):  MACROBUTTON DoFieldClick [click and type here] Name and Address  FORMCHECKBOX  Mr.  FORMCHECKBOX  Mrs.  FORMCHECKBOX  Ms.  FORMCHECKBOX  Dr.  FORMCHECKBOX  MissLast MACROBUTTON DoFieldClick [click and type here]First MACROBUTTON DoFieldClick [click and type here]Middle initial MACROBUTTON DoFieldClick [click and type here]Address MACROBUTTON DoFieldClick [click and type here]City MACROBUTTON DoFieldClick [click and type here]State MACROBUTTON DoFieldClick [click and type here]Postal code MACROBUTTON DoFieldClick [click and type here]Country MACROBUTTON DoFieldClick [click and type here]Telephone and Email Home phone MACROBUTTON DoFieldClick [click and type here]Work phone MACROBUTTON DoFieldClick [click and type here]Cell phone MACROBUTTON DoFieldClick [click and type here]Fax MACROBUTTON DoFieldClick [click and type here]Email MACROBUTTON DoFieldClick [click and type here](Email information is used for monthly statements. To receive Quantum Techniques articles, please visit our website.) Referral Information How did you hear about us?Please provide individual name or location. FORMCHECKBOX Client MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX EFT DVD MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX Workshop/Presentation MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX Family/Friend MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX Advertisement MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX Website MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX Practitioner MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX Unity Church MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX Noetic Science Group MACROBUTTON DoFieldClick [click and type here] FORMCHECKBOX Other MACROBUTTON DoFieldClick [click and type here] History Questionnaire Name:  MACROBUTTON DoFieldClick [click and type here] Age:  MACROBUTTON DoFieldClick [click and type here] Gender:  FORMCHECKBOX  Male  FORMCHECKBOX  Female Date:  MACROBUTTON DoFieldClick [click and type here] 1. Describe the issue(s) you want assistance in healing. MACROBUTTON DoFieldClick [click and type here]2. Origin of problem (if known): MACROBUTTON DoFieldClick [click and type here]3. Severity of problem: FORMCHECKBOX  Mild  FORMCHECKBOX  Moderate  FORMCHECKBOX  Severe  FORMCHECKBOX  Urgently Severe Comment: MACROBUTTON DoFieldClick [click and type here]4. How does it affect you? How does it restrict normal functions like sleeping, eating, working or relationships? MACROBUTTON DoFieldClick [click and type here]5. How long have you suffered from this problem? MACROBUTTON DoFieldClick [click and type here]6. Treatment history: What remedies and treatments have you tried? What were the results? Length of treatment(s)? MACROBUTTON DoFieldClick [click and type here]7. List any personal or family history of allergies, asthma, headaches, bowel problems or other illnesses. (These are frequently associated with food and environmental allergens.) MACROBUTTON DoFieldClick [click and type here]8. Conditions, places, circumstances and instances that evoke the current problem: MACROBUTTON DoFieldClick [click and type here]9. Please list any man-made objects in your body and the date of the surgery, for example, stents, pins, artificial joints, root canals, crowns, pacemakers, etc. MACROBUTTON DoFieldClick [click and type here]10. What surgeries, operations, traumas, accidents, etc., have you had? MACROBUTTON DoFieldClick [click and type here] Describe major scars on your body: MACROBUTTON DoFieldClick [click and type here]11. Do you have body piercings? Where are they? FORMCHECKBOX  Yes  FORMCHECKBOX  No  MACROBUTTON DoFieldClick [click and type here]12. Do you have tatoos? Where? Colors of ink? FORMCHECKBOX  Yes  FORMCHECKBOX  No  MACROBUTTON DoFieldClick [click and type here]13. Do you use tobacco? How much and how often? FORMCHECKBOX  Yes  FORMCHECKBOX  No  MACROBUTTON DoFieldClick [click and type here]14. What type of cookware do you use? FORMCHECKBOX  Stainless Steel  FORMCHECKBOX  Aluminum  FORMCHECKBOX  Iron  FORMCHECKBOX  Teflon Coated  FORMCHECKBOX  Glass/Ceramic15. Do you live or work within mile of a cell phone tower? FORMCHECKBOX  Yes  FORMCHECKBOX  No 16. Medications taken in the past for this problem: MACROBUTTON DoFieldClick [click and type here]17. Medications taken currently. How much, how often? MACROBUTTON DoFieldClick [click and type here] 18. Is there anything else you want to tell us that will allow us to more completely help you?  MACROBUTTON DoFieldClick [click and type here] Client Product Inventory Name:  MACROBUTTON DoFieldClick [click and type here] Date:  MACROBUTTON DoFieldClick [click and type here] In an effort to help the body move into a healing state, Quantum Techniques has learned that it is important to identify foods or products which the body is interpreting as an energy toxin. Please list commonly ingested foods and beverages as well as the product names of items used below and return via email or fax. This form is optional, but highly recommended. It will help your practitioner quickly and efficiently test your energy field to identify specific items which may need to be temporarily avoided as part of your complete treatment plan. Completing this form will save you treatment time on the phone. As each item is tested, circling those which need to be avoided will be a helpful reminder. Typical FoodsBreakfast MACROBUTTON DoFieldClick [click and type here]Lunch MACROBUTTON DoFieldClick [click and type here]Dinner MACROBUTTON DoFieldClick [click and type here]BeveragesWater (tap, well, bottled) MACROBUTTON DoFieldClick [click and type here]Juice types MACROBUTTON DoFieldClick [click and type here]Soda types MACROBUTTON DoFieldClick [click and type here]Soft drinks (i.e., Hi-C, lemonade, ice tea) MACROBUTTON DoFieldClick [click and type here]Milk MACROBUTTON DoFieldClick [click and type here]Coffee MACROBUTTON DoFieldClick [click and type here]Tea MACROBUTTON DoFieldClick [click and type here]Alcohol MACROBUTTON DoFieldClick [click and type here]SupplementsVitamins, minerals, etc. MACROBUTTON DoFieldClick [click and type here]Personal Care Products (Please indicate brand name such as Dove, Aubrey Organics, Crest, etc.)Soap MACROBUTTON DoFieldClick [click and type here]Moisturizing lotion/face cream MACROBUTTON DoFieldClick [click and type here]Shampoo MACROBUTTON DoFieldClick [click and type here]Conditioner MACROBUTTON DoFieldClick [click and type here]Detangler MACROBUTTON DoFieldClick [click and type here]Hairspray MACROBUTTON DoFieldClick [click and type here]Hair gel MACROBUTTON DoFieldClick [click and type here]Hairdye/highlight  MACROBUTTON DoFieldClick [click and type here]Antiperspirant/deodorant MACROBUTTON DoFieldClick [click and type here]Shave cream MACROBUTTON DoFieldClick [click and type here]Perfume/cologne MACROBUTTON DoFieldClick [click and type here]Make-up/make-up remover MACROBUTTON DoFieldClick [click and type here]Nail polish/remover MACROBUTTON DoFieldClick [click and type here]Mouthwash MACROBUTTON DoFieldClick [click and type here]Toothpaste MACROBUTTON DoFieldClick [click and type here]Floss MACROBUTTON DoFieldClick [click and type here]Whitening products MACROBUTTON DoFieldClick [click and type here]Hand soap/hand sanitizer (i.e., Purell) MACROBUTTON DoFieldClick [click and type here]Sunscreen MACROBUTTON DoFieldClick [click and type here]Bugspray MACROBUTTON DoFieldClick [click and type here]Household Cleaning Products (i.e., Fantastic, 7th Generation)All purpose cleaner MACROBUTTON DoFieldClick [click and type here]Glass cleaner MACROBUTTON DoFieldClick [click and type here]Dishwashing soap MACROBUTTON DoFieldClick [click and type here]Dishwasher detergent MACROBUTTON DoFieldClick [click and type here]Floor cleaner MACROBUTTON DoFieldClick [click and type here]Laundry detergent MACROBUTTON DoFieldClick [click and type here]Laundry stain remover  MACROBUTTON DoFieldClick [click and type here]Fabric softener MACROBUTTON DoFieldClick [click and type here]Dryer sheets MACROBUTTON DoFieldClick [click and type here]Do you use air fresheners? MACROBUTTON DoFieldClick [click and type here]Do you burn candles? MACROBUTTON DoFieldClick [click and type here]Do you burn wood in your fireplace? MACROBUTTON DoFieldClick [click and type here]Kids:Markers MACROBUTTON DoFieldClick [click and type here]Paints MACROBUTTON DoFieldClick [click and type here]Glue/rubber cement MACROBUTTON DoFieldClick [click and type here]Temporary tattoos MACROBUTTON DoFieldClick [click and type here]Stuffed animals MACROBUTTON DoFieldClick [click and type here]Favorite plastic toys MACROBUTTON DoFieldClick [click and type here]OtherDo you own a pet?  MACROBUTTON DoFieldClick [click and type here]Pet shampoo MACROBUTTON DoFieldClick [click and type here]Tic/flea repellant MACROBUTTON DoFieldClick [click and type here]Do you use lawn fertilizer/pesticide? MACROBUTTON DoFieldClick [click and type here]Do you wear jewelry?  MACROBUTTON DoFieldClick [click and type here]Gold, silver, platinum, other MACROBUTTON DoFieldClick [click and type here]Have you had any recent renovations? MACROBUTTON DoFieldClick [click and type here]New paint, new floor tile/carpet, construction of any kind MACROBUTTON DoFieldClick [click and type here]Do you send clothes out to be dry cleaned? MACROBUTTON DoFieldClick [click and type here]Cooking source (electric, natural gas, propane) MACROBUTTON DoFieldClick [click and type here] Legal and Financial Understanding Quantum Techniques Guarantee Most issues, such as those involving pain, trauma, and emotion, respond immediately to bioenergetic correction with Quantum Techniques. More complex issues involving autoimmune process or chronic illness with pathological tissue and biological agents take longer to resolve. An example would be a person with a massive fungal infection and gut dysbiosis with hidden virus and parasites. This client may need to avoid certain foods and may need to take a supplement or two to help kill off the fungus, virus and parasites along with the QT code. It may take the body time to kill off the pathogens and rebuild the gut lining. Due to the nature of Quantum Techniques and its high effectiveness, we make the following guarantee: We will evaluate and suggest a bioenergetic correction for your issue and let you experience the results overnight. If you do not believe, after overnight reflection, that you are dramatically better or that your chronic condition will benefit greatly from this work, we will fully refund your initial payment of fees. This is a one-time guarantee, and you must make this determination within 24 hours of your first session. If you choose to continue sessions, no refund will be available.  FORMCHECKBOX  Yes I have read, understood and agree with the Guarantee of Quantum Techniques as represented.Name: MACROBUTTON DoFieldClick [click and type here]Date: MACROBUTTON DoFieldClick [click and type here] Article IX, U.S. Constitution The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the People. Under the Ninth Amendment to the Constitution of the United States of America, I retain the right to freedom of choice in health care and psychological services. This includes the right to choose my diet, and to obtain, purchase and use any therapy, regimen, modality, remedy or product recommended by the therapist, doctor or any practitioner of my choice. The enumeration in this declaration of these rights shall not be construed to deny or disparage other rights retained by me, or my right to amend this declaration at any time. Constructive Notice Notice is hereby given to any person who receives a copy of this Declaration and who, acting under the color of law, intentionally interferes with the free exercise of the rights retained by me under the Ninth Amendment, as enumerated in this declaration, that they may be in violation of my civil and constitutional rights, Title 42, U.S.C. 1983 et seq. and Title 18, Section 241.  FORMCHECKBOX  Yes I have read, understood and agree with Article IX of the U.S constitution and the Constructive Notice above.Name: MACROBUTTON DoFieldClick [click and type here]Date: MACROBUTTON DoFieldClick [click and type here] The following forms must be printed, completed, signed and faxed to the Quantum Techniques billing office at 928-771-1403. Please do not email this form as it is NOT secure. If you do not have access to a fax machine, please mail the forms to: Quantum Techniques, PMB 494, 3196 Willow Creek Road, Suite A103, Prescott, AZ 86301.Payment Information Fax: (928) 771-1403 Bioenergetic correction is not typically a health insurance reimbursable item. Some medical savings plans do allow for these services if they are billed as acupressure for allergies or pain control. Bill my credit or debit card weekly for minutes I use at USD $6.67 or $7.50 per minute (see footnote below). I accept that it is my responsibility to keep track of the time I use or ask the Practitioner how much time I have used at the end of each session. Name on Credit Card:Type of Card:Credit Card Number:Expiration Date:Signature: You are welcome to use any available Practitioner at any time. Please note that when you use an on-call Practitioner who is not your customary Practitioner that you will need to provide credit card information to them at the time of your call. On-call minutes are billed at the regular rate of USD $6.67 per minute. On-call minutes for Dr. Stephen Daniel and Beth Daniel are billed at the regular rate of USD $7.50 per minute. Client Request and Authorization I, the undersigned, request that Stephen P. Daniel, FPPR, QT, Beth Daniel, QT, or any other QT practitioner listed and active on the www.quantumtechniques.com website at the time of this agreement, perform an evaluation and set up sessions for the purpose of coaching me in a self-help acupressure technique for reducing stress, enhancing my health and removing any dysfunction in my bioenergetic system. I understand that QUANTUM TECHNIQUES (QT) are not intended to diagnose, prescribe or treat any disease, physical or mental. They are also not intended as a substitute for regular medical or psychiatric care. I am not being advised by QT to discontinue any prescribed medication or medical or psychological care. I am hereby instructed to consult my personal physician for specific symptoms or medical concerns. Client Signature:Date:Printed Name: Non-Client Credit Card Authorization Fax: (928) 771-1403 If you are a QT client and someone else is paying for your treatment, this form must be completed by the credit card holder, and then printed, signed and faxed to the QT office at 928-771-1403. If you do not have access to a fax machine, please mail this form to: Quantum Techniques, PMB 494, 3196 Willow Creek Road, Suite A103, Prescott, AZ 86301. Bioenergetic correction is not typically a health insurance reimbursable item. Some medical savings plans do allow for these services if they are billed as acupressure for allergies or pain control. Bill my credit or debit card twice a month for the sessions provided to the client named below at USD$7.50 per minute or USD $6.67 per minute depending on my practitioner of choice. I understand that it is my responsibility to stay aware of the charges the client is incurring. I understand that it is the clients responsibility to keep track of the time they use. They may ask the Practitioner how much time they have used at the end of each session. QT Client Name:Name on Credit Card:Type of Card:Credit Card Number:Expiration Date:Billing Address:Phone Number:Credit Card Holder Signature: You are welcome to use any available Practitioner at any time. Please note that when you use an on-call Practitioner who is not your customary Practitioner, you will need to provide credit card information to them at the time of your call. On-call minutes are billed at the regular rate of USD $7.50 or $6.67 per minute depending on the practitioner you choose. Disclaimer, Hold Harmless, and Consent to Participate in Energy Coaching Sessions with a Quantum Techniques Practitioner I, _________________________________ (print your name here), hereby agree to participate in self-help energy coaching sessions with _________________________, a practitioner of Quantum Techniques. I have read and thoroughly considered the Disclaimer and Hold Harmless agreement below. By my signature below, given freely and without pressure from any person, I consent to the use of these methods in my healing. Disclaimer Overview Quantum Techniques (QT) are not intended to diagnose, prescribe, treat, or cure any disease, physical or mental. The use of Quantum Techniques (QT) by a QT practitioner should not be construed as a prescription, a promise of benefits, claims of cures, or a guarantee of results to be achieved. The information, instruction or advice given by a QT practitioner is not intended to be a substitute for competent professional medical or psychological diagnosis and care. You should not discontinue or modify any medication presently being taken pursuant to medical advice without obtaining approval from your healthcare professional. As a QT client, you must take complete responsibility for your own physical health and emotional wellbeing. Disclaimer Explained QT consists of self-help coaching techniques and tools, within the category of energy therapy. A client learns and uses Quantum Techniques to balance their own bodys energy system with the intention of reducing stress, enhancing overall health, and removing dysfunctions in the body's bioenergetic system. QT and its practitioners believe that it is the client who heals himself/herself, and that the QT techniques and tools simply assist the client in this process. Every QT client is unique, and therefore, each clients experience with QT may be unique. QT is not a substitute for regular medical or psychological care. QT is not about disease or illnessrather, its focus is on healing and wellness. Medical authorities do not recognize this work as medicine. We agree. There are researchers in this area who believe there is a correlation between the detection of certain energetic frequencies and the presence of disease states or organisms in the body. Energy therapies, like QT, may be able to identify the unhealthy frequencies years before a physical disease manifests in the body. As a person heals those frequencies, health is enhanced. Our work, which includes evaluations and scans of the subtle-energy field, is strictly limited to address the imbalances in the subtle-energy field. For example, in our scans we may talk about the frequencies of virus, bacteria, fungus and parasite issues. We are only saying that we have often found those frequencies when our clients are in a non healing state. Commonly, people who manifest those frequencies over time experience patterns of deterioration in the way they feel. As those frequencies are cleared and the energy field is balanced, they typically experience a return to feelings of wellness. We cannot determine if the client actually had a virus, bacteria, fungal infection or parasite. We cannot determine if a client actually has Multiple Sclerosis, Parkinsons disease, Manic Depression or HIV, for example. Testing for that is beyond our expertise. For those determinations, we refer clients to their M.D. or licensed health care professional for appropriate tests. No one is advised to discontinue or to avoid medical or psychological consultations. There are cases where medical or psychotherapeutic consultations are advised. Dont use these techniques to try to solve a problem where your common sense would tell you it is inappropriate. Since these are self-treatment techniques, we cannot and will not take responsibility for what you do with them. You are required to take complete responsibility for your own well-being both during and after the use of our materials and/or coaching sessions. Some statements on the QT web site, manuals and products represent working theory rather than accepted science. Quantum Techniques Practitioners practice as bioenergetic consultants, not as licensed medical doctors, psychologists, psychotherapists, chiropractors, lawyers, nutritionists, or naturopaths. Although these techniques are being used by therapists, health professionals and lay people worldwide, the practice of QT and bioenergetic consulting is not currently regulated by any licensing board in the United States. Any spiritual counseling provided by Quantum Techniques Practitioners is not part of any recognized religion. We have not personally experienced any adverse side effects when applying the gentle techniques of QT when the treatment protocols and suggestions were followed. This does not mean, however, that you will not experience or perceive negative side effects. If you use these techniques on yourself or others, you must agree to take full responsibility for your own well-being and you are required to advise others to do the same. You must understand that while an energy healing approach is a safe self-treatment method, with a substantial body of clinical experience showing no serious side-effects when properly administered, it is possible, with any form of healing, that unresolved memories and related emotions and sensations may be brought into your awareness. It is possible that this emotional material may continue to surface after the coaching session and require further self-treatments or coaching sessions. It is also possible that previously traumatic memories may lose their emotional charge, and this could adversely affect your ability to provide legal testimony that carries the same impact as it might have prior to treatment. In some rare cases, clients with chronic illness have reported some mild healing reaction symptoms as their body releases stored toxins. Typically this is short lived and can be addressed with another coaching session or self-treatment protocol. Hold Harmless Agreement I agree to hold harmless Stephen and Beth Daniel, the originators of QT, all QT practitioners, and anyone affiliated with QT from any claims, liability, or loss incurred directly or indirectly by me (or anyone I may teach or seek to help using QT) as a result of the use or application of any techniques or methods learned from a QT practitioner or product.  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