The Client History Form

Save & Return

Save your progress and complete this form later. OPTIONAL: However, without an account, you will not be able to return and complete if you walk away unfinished.

Thank you for choosing to provide additional information about your health history and lifestyle - this will make the first session with your practitioner flow more smoothly and be less costly!

To review the more than 90 questions that are to follow, please preview or print this entire form at The QT History Form

For TECHNICAL SUPPORT or to submit this form by telephone, contact Cheyene Stone:

Office: U.S. 855-QT Heals (784-3257) | World 1-786-567-8663 | Email: support@quantumtechniques.com

If you have questions on anything related to this process call the QT Office Manager, Cheryl DeMauro, at 928-771-1215 or 888-767-8002.

Quantum Techniques New Client History Form

Contact Information

First Name *

Last Name *

Email Address *

(Email information is used for monthly statements only.)

Telephone Number: *

Preferred Practitioner: *

Dr. Stephen P. Daniel, Ph.D, FPPR	Beth Daniel, M.A., Ed.S.
Jody King Colegrove, ACP-EFT	Dr. Carolee Johnson N.D., M.H.
Dr. Thomas Miller	Dr. David Kirkpatrick
Dr. Kristin Killops	JJ Curren
Other Other