The following informed consent is required before starting a QHHT session please:

There are no guarantees.

Peace And Conflict Resolution.Org will provide me a QHHT session with one of its volunteer, trained, QHHT practitioners. I have read this QHHT web page above and explored the links starting at (Note: ask for your practitioner)

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Richard W Buckley ("Rich Buckley"), Peace and Conflict Resolution.Org, (name of hypnotist: _________________________) from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

Your name will be held confidential. 


X_______________________   ______________________  Date:__________
                Signature:                                   Print Name         

Please print out this web page and sign and date it and bring it to your private session. The hypnotist will ask for it before starting the actual session.