BLISS INNER WELLNESS

HEAL & THRIVE
Please complete this form with as much detail as you can and submit prior to your session. Your information is important to me and will be held in the upmost confidence.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Age*
What do you wish to achieve?*
What are your current main concerns? body / mind / spirit*
Please tell me your history (injury | trauma | surgeries etc.)*
Are you currently seeing any healthcare professionals?*
How are you sleeping? (How many hours, quality etc.)*
Please read the list and tick any that you are currently feeling or have felt over the last 3 months*

CriticisedOverwhelmedApprehensiveUncertaintyAgitatedParanoidIntolerantMuddledGuiltyOverworkedAggravatedParalysedDepressedRejectedEasily IrritatedPersecutedHelplessAnxiousHopelessUneasySadDepressedGrievingAbusedFearfulUnable to GrieveDistressImpatientAngryWorriedOutragedSleeplessNervousRestlessIntimidatedNONE
Do you have any concerns about the following areas - please tick and comment below

DigestionRespiratoryCardiovascularUrinaryNervous SystemMuscle / JointsLymphatic SystemEndocrine System
Please give further details in relation to any areas ticked above or anything else you feel I should be aware of.

Please take a moment to consider the following.*

Please take a moment to consider how much time you have for each of the following.*

COMPLETE THE REST OF THE QUESTIONS BELOW IF YOU ARE CONSIDERING A FUTURE INNER CHILD OR PAST LIFE REGRESSION SESSION
Can you enter into a hypnotic state through self hypnosis? Do you have questions about what hypnosis is?
Have you experienced hypnotherapy sessions? How many. For what purpose? What was the outcome?
Have you experienced formal Past Life Regression sessions? How many? For what purpose? What was the outcome?
Have you had a Spontaneous Past Life recall?
Are you a healer? In what modalities?
Have you met or do you know your Spirit Guides? Describe
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
What are your feelings, thoughts and questions about your issues?
How does this issue affect you? Describe a specific moment in the last few weeks to illustrate, including what you saw, heard and felt.
How long has this been an issue? Has it changed over time?
Would you like to be on my mailing list. No spam! Just updates.

YesNo
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.
What information or therory do you already have about the cause and nature of your issue?
What outcomes would you like to get after the sessions
Do you have specific questions you would like to have answered?
How did you hear about me
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HEAL & THRIVE