"You've always been enough. Use the resources all around you to create a life you want to experience. A life full of joy and love. The spirit world will nudge you through synchronicity. You can do it" -Source


WA State Business Lic. #604-121-489

Client In-Take Form

Merkaba Chakras QHHT logo

Client In-Take Form


Merkaba Chakras QHHT

Client In-Take Form

Practitioner: Von Galt, (206) 574-8844





Name: ________________________________________________________

Phone Number: _________________          Email: __________________          

Date of Birth: _________________              Age: ___________                                        


DISCLAIMER: The QHHT practitioner is not a healer. The practitioner can only facilitate the QHHT regression. QHHT is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The Client In-Take form is intended to prepare for QHHT. However, its insightful when completed honestly. QHHT allows a client to communicate with the Over Soul to garner a deeper understanding about their soul’s growth. This is for exploratory purposes. 



There are three parts to the session: 4 Hrs


  1. Interview and go over your questions you have for the Over-Soul. I also use a dowsing rod to measure the health of my client's chakras before a session.
  2. The QHHT Regression. 
  3. Recap interview and an updated energy dowsing.


Below are the guidelines for common questions you want to have ready for your QHHT session.



List your soul group:









Significant Friend(s):






Briefly describe your childhood in 5 sentences or less.


When you look at a picture of the people in your soul group…

            Do you feel any ANGER with any of these people?




            Do you feel any GRIEF with any of these people?




            Do you feel any WORRY with any of these people?




            Do you feel any STRESS with any of these people?




            Do you feel any FEAR with any of these people?




Why do you think you picked the parents that you have?


What vows (i.e. vow of poverty, celibacy, obedience, etc.) or Soul Contracts (between specific persons) do you want to explore?


If you died now, do you have any regrets?


Do you think you are enough?




If you have a pain, when did it start? What happened in your life at this time? Was there a person that causes negativity in you that entered your life at this time?


List any illnesses:


List any recurring injuries:


What are your symptoms?


What parts of the body are affected?


Do you have any physical pains that you avoid addressing that may have moved into your organs?


List any recurring issues in your relationships?


List any recurring issues in your career choices?


List the #1 recurring theme (positive/negative) or issue you deal with?


List a couple recurring secondary themes (positive/negative) or issues you deal with?






Below are a set of questions asked of the Over Soul in every QHHT.


If you have any deceased loved ones or anyone in the spirit world you would like the Over Soul to bring forward 1st so that you can connect with them, then please list their names and your questions:

  • Spirit World Connection #1:
  • Spirit World Connection #2:
  • Spirit World Connection #3:


What lessons can I learn from my parents whom I choose to be born through?


Why did I choose them?


What lessons can I learn through the recurring themes in my life?


What lessons can I take with me from my regressions?


What is my purpose?


What advice can my Over Soul give me to have peaceful relationships and live a balanced lifestyle?


List any questions about your life journey and personal requests for the Over Soul to please remove such as quit smoking, exercise and eat better, remove the migraine headaches, pain in your joints, etc.


Your list of questions for the Over Soul:


Is he/she a Starseed? Origins?


Why did he/she incarnate here on Earth at this time?


Does he/she have any negative energy to remove?


Any last “fun” questions? Examples are aliens, Bigfoot, ancient archaeology, Earth’s future, etc.

Your list of “fun” questions for the Over Soul:



  1. Fill out the client in-take form as best you can.
  2. Please download a recording app on your cell phone or iPad, which you will use as a back-up to record your session. Be sure to test it and make sure it has at least 4 hours of memory in the app beforehand. Bring your charger with you to the session.
  3. Be sure to eat before you come, wear comfortable clothes, and let your loved ones know that you will not be available during the session.
  4. Please review these pages within the Merkaba Chakras website:









Circle the areas of the body you want to address where pain exists. Please make notations in the empty space below to explain the issue further.


Basic and More Complex Information About the Chakras






Surrogate Alternatives: Surrogates doing the QHHT session on behalf of someone who gave permission for a surrogate to take their place are done when one of these conditions are met. 


1. Mental health issues (personality disorders, etc.)

2. Language barriers (must be fluent English speaking)

3. Hearing impaired (must be able to hear the practitioner)

4. Minors under 16-years old. 


View my practitioner profile on Dolores Cannon's QHHT registry:




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