Quantum Soul Healing / Past Life Regression Consultation Form

Quantum Soul Healing / Past Life Regression Consultation Form

The purpose of this questionnaire is obtain a comprehensive picture of your background and current circumstances. By completing the questions as fully and as accurately as you possibly can it will assist me greatly to maximise your session.
Name

First NameLast Name
Email address to receive a copy of this form
example@example.com
Date Of Birth

MonthDayYear
Date
Date of session with Sally-Ann ( Your Time Zone )
Phone Number (drop the 0 if in the UK )
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState/ Region

Postcode/ Zip Code

What Is Your Occupation ?
What Is Your Gender ?
What Is Your Relationship Status ?
Prior Experience With Hypnotherapy?
An Emergency Contact Person is required incase of technology issues or if I have any concerns for your well being. This person must have the ability tophysically check on you during your session time. Please provide their name & phone details below.
Emergency Contact Name
Phone Number

AnxietyFearWorryScarcityLack of grounding
Divorce or bad break upParents divorcingLoss of financeLoss of houseExtreme terrorPhysical issues at base of spine (sciatica/ twisted spine)Physical issues with hipsPhysical issues with knees or ankles
Please give more detail if you have ticked any of above boxes
SexDepressionLack of creativityLack of joySadnessMarriage/ Relationship
Sexual abuse / RapeSuppression in relationshipsLack of connection with your MotherLoss of a child
Womb/ ovaries / fallopian tubesProstateBladderIBS/ Colitis/ Celiac/ Candida
Please give more detail if you have ticked any of the above boxes
InsecurityLack of confidenceGuiltShameAlcoholAppetite/ eatingPorn addictionAnorexia/ BulimiaJealousyObsessions/ compulsions/ OCDSports performanceWeightHabits
Shaming by someoneBeing controlled by someoneBeing bullied by someoneMade to feel overweight by someoneextreme terror
Stomach issuesLiver issuesKidney stonesWeight/ Appetite/ eating
Please give more detail if you have ticked any of the above boxes
GriefHeartbreakLack of heart connection with parents as a childUnable to connect at the heart
Heart problemsChest or lung problems
Please give more detail if you have ticked any of the above boxes
SmokingThroat issuesPain or discomfort in shoulder bladesPain in back of neck/ top of spinePain in arms & handsTalking too muchSaying inappropriate thingsSaying vicious things whilst under the influence of alcoholTeeth of gum issuesThyroid issues
Told not to speakIgnored as a childSuppressed voice
Please give more detail if you have ticked any of the above boxes
Seeing scary images in the mindHearing voicesLack of imaginationUnable to connect when meditatingA feeling of being able to "see" more than others in the third eye
Saw "things" as a child and were shamed or told you were being "silly"Traumatic experiences whilst meditatingHave you taken any form of psychedelic drug
What Drug/s have you taken and your experience you had
Problems with brain/ mindProblems with eyesProblems with earsMigraines
Please give more detail if you have ticked any of the above boxes
Hair lossPressure on and above the headInability to meditateReligious dogmaProblems with scalp
SleepWorkSuicidePainDrugsAlcoholStudyingPanic AttacksAllergiesPTSD
Please give more detail if you have ticked any of the above boxes
Any Problems Not Listed Above?
Do you spent too much time on social media / mobile phone or game heavily?
Please provide details
Any Traumatic Experiences in your life? Please explain and give details below.
Do you have any Phobias? Please explain in a detailed way below.
List the people who are important in your life and their relationship to you
MEDICAL HISTORY

Please answer the following questions in confidence
Have you had any hospital visits/ stay overs?
please give details
Do you have a diagnosed medical illness?
Please indicate name of illness or none
Do you have a diagnosed Psychological problem?
Please indicate name of diagnosis or none
Is your General Practitioner aware of the above problems?
Pleas type YES / NO or not applicable
Give a full list of any medications you are taking or otherwise state none.
Do you have any hearing problems?
How are your sleeping patterns?
What health questions would you like to ask in the session?
Are you currently pregnant?
How many pregnancies have you had? (if applicable)
How were you led to me ?
List up to 10 Questions for your Higher self this will be used in session number 2
What do you hope to achieve with our session? Please give as much detail as possible
Is there any other information/ concerns you would like me to know before we meet online or in person on the day?
Technical checklist for online clients ( for face to face clients you will still have to tick the boxes for the form to work)

Please confirm the following checks are in place before we meet on the day of your session.
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
I understand that the success of the soul healing / Past Life Regression Session is based around my willingness to relax and push my conscious mind to the side. I also understand that the price of the session is for Sally-Ann's time as a clinical Hypnotherapist trained in Hypnotherapy & Past Life Regression techniques. I understand that it is my responsability to provide myself with a safe and comfortable environment in order to take an online session. I also understand that if the iinternet connection should go down during the session all I have to do to come out of the Theta State is to gradually become more alert until I am fully conscious.I also understand that it is my responsabilityto provide a stable internet connection and attend the session with a working headset that has a microphone that can be placed in front of the mouth.I understand that the price of one session is £220 payable at the time of the booking and any cancellations requires 72hrs notice. The price for 2 sessions 2-3 weeks apart is £349 for the maximum benefit as it is important to clear any entities & attachments to make sure we are connecting to your true higher self and past life experience in session 2. I understand that if I ticked YES to say that I agree to share my information anonymously, that Sally-Ann will share on social media platforms she is on.(It will be audio only with small sections of the recording which may help others)I also understand that if I ticked NO to sharing anonymised information then Sally-Ann will NOT share any of my audio recording.
Date

MonthDayYear
Date
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