Past Life Regression Intake

Your Full Name *

Email *

Date of Birth *

City and State Where you Live *

Phone Number *

Occupation *

Relationship Status *

Partner Name

Partner Occupation

Children's Names and Ages

Family History: Please check all that apply to your blood relatives *

Problems Drinking or Alcoholism
Substance abuse or drug addiction
Suicide or Frequent Suicide Attempts
Depression or other emotional problems
History of child, family, or sexual abuse
None - Does not apply

Here is a list of common difficulties which often lead people to seek professional assistance. Please check all that apply to you. * *

If you answere Trauma to the question above please briefly describe your trauma history

Do you use food, alcohol, or drugs to relieve tension? If so, what specifically do you use and how often? If this does not apply to you, write N/A below. *

Please describe your current state of health. *

Have you ever been in counseling or psychotherapy? If so, how long, why did you seek therapy and what were your results? *

Are there any issues, problems, blocks you're currently dealing with you feel is karmic? *

Do you experience any phobias or "irrational" fears currently that have no ties to this lifetime? What do you fear? *

What would you say is your main concern at this time? *

Do you have any experience with meditation? Don't worry, this isn't required know-how, it will just help me during your session. *

Yes! I do it all the time
No, never tried it or have struggled with it
Kind of - I've done it but wouldn't say I have a meditation "Practice"

Have you ever been in hypnosis? *

Briefly, why have you booked a session and what do you hope to achieve? *

What would you like to have answers to or resolve during your session? It could be an annoying pattern, clarity on a relationship, or anything in between! *

Is there anything specific you're wanting from your session? Keep in mind, we're going into the infinite! That means all information is possible. Are you missing a skill in this lifetime? Confidence? Or an experience you'd really like to have - what are you WANTING more of in this lifetime?

To the best of my knowledge, the above information is true and correct and I hereby declare that I attend this session of my own free will and take full responsibility for my own well-being. *

I agree

Past Life Regression Intake Form