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Information Request Form
An online information request form to give your visitors an information request platform.
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1
Name
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First Name
Last Name
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2
E-mail
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example@example.com
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3
Date
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Date
Month
Day
Year
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4
Podcast Recording Permission
*
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I sometimes share past life regression and healing sessions on my podcast as a way to help others learn about the process and explore their own healing journeys. If you choose to give permission, your session recording
may be used in a future podcast episode
. Any
personal, sensitive, or identifying information will be edited out before publication
to protect your privacy. You are under
no obligation
to grant permission, and your decision will
not affect the quality or availability of your session in any way
.
Do you give permission for your session recording to potentially be used on the podcast under these conditions?
Yes, I give permission
No I do not give my permission
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5
By checking this box, I acknowledge that I have been informed that the practitioner is not a licensed therapist, or certified hypnotherapist, and is in no way claiming to be such. I agree that I am willing to be guided through relaxation, visual imagery, creative visualization, hypnosis, stress reduction processes and techniques for the purpose of vocational or advocational self-improvement. I understand that the meditations I am receiving are not a substitute for normal medical care and I have been advised to discuss this hypnosis or other treatment with any doctor who is taking care of me now or in the future. I shall continue my present medical treatment and consult my primary care doctor for treatment of any new or old illnesses. In addition to the previous conditions, I also acknowledge that participation in these meditations is for the purpose of relaxation, and entertainment, and in no way claiming to cure or treat any illness, or condition, mental, physical, treatable, terminal or otherwise. I agree that in the rare circumstance of emotional, mental, or other discomfort, or new symptoms of a physical, or psychological condition the practitioner will not be held liable, and I will consult a medical doctor or licensed mental health professional for treatment of any new or existing mental or physical health conditions or symptoms.
*
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I Agree
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6
Signature
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