Past Life Regression Therapy Hypnotherapy Intake Form

This intake is important and will be closely read. A well completed form is required to be appropriate to receive hypnotherapy sessions. The more you put into the process, the more you get out of it.

First name*

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Last name*

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Email*

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Phone

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Can you enter into a hypnotic state? Have you practiced self hypnosis? Do you have any questions about what hypnosis is?

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2) Have you experienced hypnosis or hypnotherapy sessions? How many? For what purpose? What was the outcome?

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3) Have you experienced formal Past Life Regression sessions? How many? For what purpose? What was the outcome?

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4) Have you had spontaneous Past Life recall? Describe

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5) Are you a healer? In what modalities?

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6) Have you met or do you know your Spirit Guides? Describe

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7) What Present Life issue do you want to focus on with PLRT? What is your compelling need for a session? What issue are you now facing that is causing significant pain and requires a therapeutic resolution?

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8) What are your feelings, thoughts and questions about your issue?

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9) How does the issue affect you? Describe a specific moment in the last few weeks to illustrate, including what you saw, heard and felt.

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10) How long has this been an issue? Has it changed over time?

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11) Who are the Key People involved in your present life issues? Describe your relationship with them in this life, and the current state of relationship.

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12) What information or theory do you already have about the cause and nature of your issue?

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13) What outcomes would you like to get after the sessions?

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14) Do you have a question you would like to have answered?

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Do you have a headset with built in microphone? A camara that captures your face, upper body, with good light? Do you have a solid device and Wi-fi that is stable for 90 plus minutes? These are all required.

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Can you attend three to five personal sessions, once a week for three to five weeks?

Do you require Donation Based Sessions? Why?*

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Do you agree with our RELEASE, WAIVER OF LIABILITY, AND BOOKING POLICY AGREEMENT*

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Signature

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226-499-3797 Extension 800

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